Student Support Services Application

Step 1: Demographic Data

Applicant Information

Applicant Name:
First Name:Middle Initial:Last Name:

Bearcat ID #:

Birthdate:

Campus Address:

Home Address:

City:

State:
- Select - Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code:

Preferred Contact Method:
- Select - Northwest Email Personal Email Cell Phone Home Phone No Preference

Northwest Email:

Personal Email:

Cell Phone #:

Home Phone #:

School Information

High School Name:

High School City:

High School GPA/Scale:

University Status:

Freshman
Sophomore
Junior
Senior
Transfer
Name of University/College:

Demographic

Gender:

Female
Male
Other

Ethnic Background:

Non-Hispanic
Hispanic

Racial Background:
White
African American/Black
Asian
Native Hawaiian or Other Pacific Island
American Indian or Alaskan Native

Are you a U.S. citizen?

Yes
No

Are/were you any of the following?

English as a Second Language
Homeless
Foster Child
Military Veteran

Parent Information

Have either of your parents/guardians received a bachelor’s degree?

Yes
No

Father's Education: (mark highest level completed)

Less than High School
GED
High School Graduate
Associate's Degree (2 Yr.)
Bachelor's Degree (4 Yr.)
Graduate Degree

Mother's Education: (mark highest level completed)

Less than High School
GED
High School Graduate
Associate's Degree (2 Yr.)
Bachelor's Degree (4 Yr.)
Graduate Degree

Statement of Disability

Do you have a physical, mental or documented learning disability which requires special accommodations to help you succeed academically?

Yes
No

If yes, specifically state the disability below and include documentation with your application.

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Step 2: Income Eligibility

Do you have an application for Federal Financial Aid (FAFSA) on file with Northwest Missouri State's Office of Scholarship and Financial Assistance?

Yes
No

Do you qualify for financial assistance? (check all you applied for)

Pell Grants
Scholarships
Vocational Rehabilitation
Work Study
Military/VA Assistance

Parent Marital Status: (student, if independent)

Married
Divorced
Separated
Single

I (if independent status) or my parents and/or guardians did not file a tax return because taxable income was less than the amount required for filing a return. (Leave blank, if no.)

How did you hear about the Student Support Services Program?

Academic Advising
Admissions Office
ASSIST
Brochure/Poster
College Bound
Educational Talent Search
Financial Aid Office
Gear Up
Instructor
Kauffman Scholars
Student Athlete Success Program
Student Success Center
Upward Bound/UBMS
Vocational Rehabilitation
Wellness Center/PDC
TRIO Staff/Student
Name of TRIO Staff/Student
Other
Specify other

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Step 3: Assessment Data

Are you a TRIO alum?

Yes
No

If yes, please list program:

Do you plan to graduate with a bachelor's degree from Northwest?

Yes
No

Please state briefly (approx. 500 words) why you would like to be a part of the TRIO Student Support Services Program.

Characters Remaining: characters remaining

What is your major/minor?

Deciding

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Step 4: Student Performance Agreement

I understand that the Student Support Services Program will use the data provided on this form to assist in assessing any academic and/or career planning needs and that all of the information will be kept confidential. I release the following information to the Student Support Services (SSS) Staff: high school transcripts, SAT/ACT scores, Northwest graduate reports and instructor evaluations, financial assistance award notices and income information, vocational rehabilitation records and any other information from my academic records pertaining to my enrollment in Student Support Services. Submitting this application verifies that all information contained herein is true and complete.

Yes
No

The purpose of this agreement is to confirm that student members are aware of the minimum requirements and responsibilities of being in the Student Support Services Program. Active membership requires involvement in activities as well as meeting with student and professional staff. Our goal is to have members working towards completing a college degree who are successful academically, mentally and socially. Students enrolled in our program will be enrolled in the program for up to six years or graduation from Northwest Missouri State University, whichever comes first.

Student Member Responsibilities

Please read and agree to demonstrate your commitment:

Meet with Academic Success Coach twice each semester, more as needed.	Yes No
Will have contact with the financial literacy coordinator annually and as needed.	Yes No
Meet with SSS peer mentor (continuing participants) twice each semester or more as needed.	Yes No
Attend at least three events as organized by SSS peer mentors and professional staff.	Yes No
Improve my academic skills by utilizing one or more resources below: Meet with a tutor in the Student Success Center (SSC), Math Lab or Writing Center. Meet with my student mentor for pre-tutoring sessions	Yes No
At any time my grades fall within an at-risk status, I am required to meet with professional staff for an academic recovery plan.	Yes No

Confidentiality Agreement

All are expected to follow a code of ethics designed to protect both you and the staff. What you discuss with peer mentors will be confidential between the peer mentors and professional staff. You have the right to see one of the professional staff instead of a peer mentor. You have the right to see any documentation as recorded by peer mentor staff. Information in your file may be used for statistical and /or research information, but your name will be kept confidential at all times and used only to comply with federal reporting requirements

Yes No

Northwest Missouri State University Academic and Professional Waiver

I give my permission to the TRIO and Student Support Services professional staff (SSS assistant director, academic success coach, financial literacy coordinator) to do the following: I authorize the release of academic, financial and any other information in my SSS files unless and until this authorization is specifically withdrawn in writing by me. I authorize the release of my records to and from when necessary: parents/guardians, instructors at Northwest, the Office of Equity and Accessibility, Vocational Rehabilitation counselors, Wellness Center and other professional personnel when needed. I authorize the release of academic records from the Registrar’s Office, Advisement Office, Admissions Office, Student Success Center and the ASSIST Program for semester reports that include and are not limited to grade reports, class enrollment, tutoring reports, graduation reports, SAT/ACT Scores, transcripts (high school, other post-secondary institutions, Northwest). I authorize SSS staff to receive information from and communication with any Northwest departments and other Northwest administrators and on my behalf when the sole purpose is to promote educational opportunities for me.

Yes No

Student with Disabilities Waiver

I Student with Disabilities Waiver - Select - Do Do not Does not apply to me  give my permission to the TRIO and Student Support Services professional staff and peer mentor staff to share limited disability-related information about me with my mentor so that they may adequately assist me in my academic progression and success at Northwest Missouri State University.

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By submitting this form, I certify that all the information I have typed into this form is correct and I understand that any false information (or omissions) in the contract agreement or its supporting documents will be sufficient grounds for my dismissal in the TRIO Summer Bridge Scholars program. I agree to all the above statements and will fully participate in the TRIO Summer Bridge Scholars program.

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To retain a copy of this application for your records,
PLEASE PRINT THIS PAGE NOW!

 

    

 

Northwest Missouri State University
TRIO SSS Office
Administration Building 372 - West Wing
800 University Dr.
Maryville, MO 64468

Phone: 660.562.1862
Fax: 660.562.1631
E-mail: ssswebp@nwmissouri.edu

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