Fillable TUDENT DATA FORM S * Required Student Social (New York University)

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TUDENT DATA FORM S * Required Student Social (New York University)

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S
TUDENT DATA FORM
OFFICE OF SPECIAL SERVICES Today’s Date:
* Required Student Social Security#
*1) Name_____________________________ Univ I.D.# N
Last First Middle
*2) Gender? Male Female Birth Date:
*3) Is this your first semester transferring from another college/university? Yes No
*4) Ethnicity - Hispanic/Latino: Yes No
*5) Race - Check at least one:
American Indian/Alaskan Native Asian Black or African-American White
Native Hawaiian or Other Pacific Islander
*6) Are you a citizen of the USA? Yes No If No: Country of Citizenship
Permanent Resident#
7) According to the last U.S. tax form filed, answer the following:
The number of members in the household is: ____ and the amount of taxable income is:
8)
Do you have any physical or learning disability?
No Yes: If yes, explain:
If ‘Yes’, have you registered with the Moses Center for Students with Disabilities? No Yes
______
You MUST answer either question A or question B (If you have any questions, please ask).
A. If your parents are not divorced or separated, check one:
Yes, at least one of my parents have a 4 year university degree
No, neither of my parents has a 4 year university degree
OR
B. If your parents are divorced or separated, check:
The parent I am living with has a four year university degree
Yes No
AND
The parent I am NOT living with provides me with substantial and regular financial support
Yes No If Yes, does this parent have a 4 year degree? Yes No
How did you find out about the Office of Special Services- TRIO Program? Check One:
1. E-mail 2. My Poly 3. Mailing 4. Flyer 5. Poly Student 6. Poly Staff
7. Other (please specify):
For Office Use
Only
_____LI & FG
_____LI
_____FG
____ Dis
____ Dis & LI
The Office of Special Services is primarily funded by the U.S. Department of Education, which requests the collection of
the above information for statistical purposes.
I
understand that the Office of Special Services has my permission to verify the information provided above and will
have access to my academic, admissions and financial aid information. *I further understand that when necessary, the
Office of Special Services staff may share information regarding students performance, adjustment, etc. with other
administrative and academic offices
Signature____________________________________ Date_______________________
Updated 7/13
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TUDENT DATA FORM S * Required Student Social (New York University)

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Completed 23 July 2020

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