STUDENT SUPPORT SERVICES APPLICATION

Student Support Services | Student Application

Student Information

First
Last
Middle Initial
Number, Street/PO Box
City, State, Zip
Residence Hall, Room #, PSC Box #
Off Campus Address
Home
Cell
Local
Most frequently used
--/--/----
Optional
Optional

Educational Information

Month/year
(--/--/----)

Program Eligibility

Academic Goals/Career Plans

Statement of Agreement and Consent

I affirm that the information provided by me on this application is, to the best of my knowledge, true and correct. Furthermore, I understand that by applying for this program, I authorize TRiO - SSS to confer with PSC faculty and staff and gather necessary information in order to provide me with the services that I have requested and to make reports to the U.S. Department of Education for the re-funding of this program. I understand that the information will be kept confidential and will be used for the following specified purposes: a) student demographic data and recordkeeping, b) program evaluation, c) needs assessment, d) federal reporting, e) other administrative purposes.
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