Last Name    First Name       M.I. 

Mailing Address  

City    Dorm  Select BANKS HUGHES MILLER Room Number 

ST       Zip      Telephone Number  --

Race/Ethnicity Please select from the following 1=American Indian or Alaska Native 2=Asian 3=Black or African American 4=Hispanic or Latino 5=White 6=Native Hawaiian or Pacific Islander 7=More than one race 0=No response          Gender  Select 1=Male 2=Female

SS # --                 Date of Birth // 

Email Address    

I am currently enrolled in hours in the Select DAY EVENING BOTH program.

Select YES NO I AM A CITIZEN, NATIONAL, ELIGIBLE NON-CITIZEN OR PERMANENT         

                   RESIDENT OF THE UNITED STATES.

Select YES NO MY CUSTODIAL PARENT(S) OR PRIMARY LEGAL GUARDIAN(S) HAS A  

                   BACHELOR'S DEGREE.  SPECIFY WHO: 

Select YES NO I HAVE A DIAGNOSED LEARNING, PHYSICAL OR MENTAL DISABILITY.

Select YES NO I APPLIED FOR FEDERAL FINANCIAL AID.  (FAFSA, ETC)

Select 1 2 3 4 5 6 7 8 9 10 11 12 12 + INDICATE THE NUMBER OF PERSONS IN YOUR HOUSEHOLD.

                   APPROXIMATE YEARLY FAMILY GROSS INCOME: 

Select YES NO I HAVE ATTENDED COLLEGE BEFORE....WHEN? 

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I AUTHORIZE THE RELEASE OF APPROPRIATE AND/OR PERSONAL DOCUMENTS AND INFORMATION TO SSS STAFF MEMBERS, INCLUDING GRADES AND FINANCIAL AID INFORMATION, NECESSARY TO VERIFY MY ELIGIBILITY AND MONITOR MY PROGRESS IN THE SSS PROGRAM, SHOULD I BE DETERMINED ELIGIBLE.  I UNDERSTAND ALL INFORMATION OBTAINED WILL REMAIN CONFIDENTIAL.