A-Z Index

Student Support Services Application

  1. COMPLETE: Please read each question carefully and complete all sections. If you fail to answer all of the necessary questions, your application will be returned to you for completion. The information you provide on this form will be kept confidential.

  2. INCOME ELIGIBITY: We will request your financial records from the Office of Scholarships and Financial Assistance for review.

  3. DISABILITY: Please attach any documentation of a disability that has been verified by your doctor/professional. This would include a previous IEP (Individual Educational Plan) or letter from your previous academic institution (if applicable).

  4. TRANSCRIPTS: Your Academic Transcripts/Records will be requested from the Admissions Office by staff from Student Support Services (SSS). You will not need to provide them.

  5. INTERVIEW: You will be contacted after turning in your application to interview with an SSS staff member in person. The interview will last 15-20 minutes.

  6. QUESTIONS: If you have questions about the application process, please call our office at 660.562.1862.

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All fields are required.

Step 1: Demographic Data

Applicant Information

Applicant Name:

School Information

University Status:


Ethnic Background:
Racial Background:
Are you a U.S. citizen?
Are/were you any of the following?

Parent Information

Have either of your parents/guardians received a bachelor’s degree?
Father's Education: (mark highest level completed)
Mother's Education: (mark highest level completed)

Statement of Disability

Do you have a physical, mental, or documented learning disability?

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?
Do you qualify for financial assistance? (check all you applied for)
Parent Marital Status: (student, if independent)
How did you hear about the Student Support Services Program?

Step 3: Assessment Data

Are you a TRIO alum?

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

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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.

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.

Will have contact with the financial literacy coordinator annually and as needed.

Meet with SSS peer mentor (continuing participants) twice each semester or more as needed.

Attend at least three events as organized by SSS peer mentors and professional staff.

Improve my academic skills by utilizing one or more resources below:

  1. Meet with a tutor in the Student Success Center (SSC), Math Lab or Writing Center.
  2. Meet with my student mentor for pre-tutoring sessions

At any time my grades fall within an at-risk status, I am required to meet with professional staff for an academic recovery plan.

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

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.

Student with Disabilities Waiver

 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.

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.

To retain a copy of this application for your records,




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

Phone: 660.562.1862
Fax: 660.562.1631