PERSONAL INFORMATION Last Name: First Name: MI:

Date of Birth: Social Security #: Student ID#:

Dorm or Local Address: City: State: Zip Code:

Cell or Local: E-Mail:

Permanent Home Address:

City: State: Zip Code: Phone:

Residency: US Citizen Gender: Permanent Resident

Resident Alien # Veteran: (Yes or No) Reservist/National Guard: (Yes or No) Ethnicity: Race: Marital Status:

Place an X next to all that apply to you:

Foster Child Homeless What is your primary language spoken at home? ACADEMIC INFORMATION Have you ever been a TRiO participant? (Yes or No)

Program: Upward Bound Talent Search Student Support Services Ed Opportunity Location: Major/Academic Interest: Current Grade Level/GPA: What is your long term educational goal? (Place an X next to all that applies) Bachelor’s degree Graduate Degree Doctorial/Professional Degree What is your EWC class standing? (Place an X next to all that applies) New Freshman Transfer Existing EWC Student Sophomore Junior Senior How did you learn about the Student Support Services TRiO Program? Counselor Teacher Friend Mail Website Other

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ALL SECTIONS MUST BE COMPLETED AND SIGNED.

INCOME STATUS

What was your Family’s Household Taxable Income for last year? (Line 6 on 1040EZ / Line 27 on 1040A / Line 43 on 1040) Household Taxable Income is household income after deductions are taken.

Number of people in household

Do you reside with your Mother Father Both Other

Are you considered an independent student? (Yes or No) Do you (the student) have children? (Yes or No)

Are you receiving financial aid? (Yes or No) How much did you receive?

Place an X next to all that apply: Pell Grant Work-study Scholarships Loan Other

Student Signature Date

Parent Signature Date _____________ All of the information provided under Income Status is true to the best of my knowledge. FIRST GENERATION STATUS Highest educational level or grade level completed by your parents: (Place an X under all that applies)

Mother Father OR Guardian Did not complete High School High School or GED 2-year degree Some college Bachelor degree or higher

Student Signature Date_____________ All of the information provided under First Generation Status is true to the best of my knowledge. DISABILITY STATUS

Do you have an impairment that limits one or more major life activities (e.g. physical or mental disability, ADHD, ADD, learning disability, mental health diagnosis, etc.)? (Yes or No)

Explain:________________________________________________________

If you want to be considered for the program based on a disability, you MUST provide documentation to the Disability Support Services Center Office at EWC. For more information, call 904-470-8157.

Student Signature Date______________

All of the information provided under Disability Status is true to the best of my knowledge.

ELIGIBILITY CRITERIA The following information is used to determine eligibility for SSS.

Failure to complete the following information may significantly delay review of your application.

TELL US ABOUT YOU!

Why do you want to participate in the Student Support Services Program?

Please describe your main concern(s) you have about being in college.

Individual Needs Assessment Place an X next to all that apply to you: Academics

I am unsure if high school prepared me for college

I need to develop my math skills I need to develop my writing skills

I am not sure what study strategies work for me

It’s been more than 5 years

since I have been in school

I need to develop time management skills

Afraid of failing in college

Achieved a GED

English is a not my primary language

Major/Career

I don’t know which majors or careers would be a good fit for me

I have a lot of interests but can’t seem to pick one major

I am not sure what careers match my interests or skills I am not sure what type of job I can get with my degree I have decided on a major but not sure I have the preparation to succeed in it I am not sure about my post-graduate options and how to apply to medical, law, or graduate programs

Personal

I plan to work over 15 hours a week & attend school full time

I have significant family responsibilities (children, siblings, parents)

I am entering college as a non-traditional age student

I am undecided about whether college is for me

I have difficulty meeting new people

I feel guilty about leaving home to attend college

Some of my family and friends do not support me attending college

I am concerned about financing my college education

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COMMITMENT TO ACTIVELY PARTICIPATE:

If accepted into Student Support Services, I understand that I may lose my status as a SSS participant if I do not follow the terms of this agreement. I agree to the following:

I will attend the SSS Welcome Event.

I will meet with my SSS Counselor at least TWO times a semester.

I will attend required SSS workshops, cultural events, or academic enhancement events (skill-building workshops, peer-tutoring, etc.) each semester.

I will follow the Academic Success Plan created by me and my SSS Academic Counselor.

If required, I will review my Early Academic Awareness reports each semester and discuss my grades with my SSS Academic Counselor.

I will participate in the tutoring program as needed throughout the academic year.

I will attend all classes and complete all work in a timely manner.

I will be honest and conscientious with my SSS Counselor and use the services of SSS to help me be a successful college student.

I will abide by ALL rules and policies set forth by the Program Director, as they relate to: Use of the labs, printing privileges, tutoring, workshops, and seminars, etc.

I give my consent the Edward Waters College Student Support Services program to use my photo and provide information on my participation in the SSS program in the SSS website and Facebook Page, brochures and newsletters. This agreement remains in effect during my years as a student at EWC.

I hereby authorize the Student Support Services Staff to access my academic and financial records and to request attendance and performance information from my instructors on my behalf. I hereby authorize my instructors to release such information. I release the staff of Student Support Services and my instructors from all legal responsibility or liability that may arise from the actions I have authorized.

AGREEMENT I certify that the information I have provided on this application is, to the best of my knowledge, complete and correct. Furthermore, I understand that by applying for the TRiO Student Support Services program, I authorize the program staff to obtain records or data pertinent to my participation from other sources, and to release information, as required by law or the terms of the Student Support Services grant, to the grant funding agency of the United States government. The Student Support Services program staff has my permission to communicate verbally and otherwise with staff, faculty, and/or off campus professionals on my behalf.

______________________________ ______________ Signature Date

Drop off completed application to: TRiO Student Support Services 3rd Fl, Centennial Building Edward Waters College, 1658 Kings Rd, Jacksonville, FL 32209

Student Support Services is funded by the U.S. Department of Education. Acceptance into the program is contingent upon meeting eligibility criteria and space availability.

Contact us: E-mail:selah.bisho0911@ewc.edu

Facebook: facebook.com/SSSatEWC

Phone: 904-470-8145

TRiO_SSS@ewc.edu