Submit completed application to Student Support Services: By Mail: PO Box 10007 Beaumont, Texas 77710 In Person: Setzer Student

Center, Room 241 (across from the game room)

Call with any questions: 409-880-7920 Visit our website: http://dept.lamar.edu/studentsupport/

APPLICATION FOR LAMAR UNIVERSITY STUDENT SUPPORT SERVICES

Personal Information
Name ____________________________________________________________________________________
Last First Middle

Birth Date _____________________________________ Gender: Female Male Race/Ethnicity: Black (non-Hispanic) Hispanic/Latino
Street or P.O. Box

SS# or ID#_________ - _____ - _________

Citizenship: U.S. Citizen Permanent Resident Caucasian American Indian Asian/Pacific Islander Other __________________________________________
City State Zip Code

Local Address_____________________________________________________________________________ Local Telephone Number (

Street or P.O. Box

)___________________________________________________________
City State Zip Code

Permanent Address_________________________________________________________________________ Cell Phone Number ( )________________________________________________________________

E-mail Address ____________________________________________________________________________ Have you participated in other TRIO Programs? Yes No (if yes, please check which one) Educational Talent Search Upward Bound McNair Scholars Educational Opportunity Centers At what school? ____________________________________________________________________________ How did you hear about Student Support Services? _____________________________________________
How do you hope to benefit from Student Support Services? ______________________________________________ __________________________________________________________________________________________________

Emergency Contact Information

Name ___________________________________ Phone Number (
Street or P.O. Box City

)__________________________
State Zip Code

Address __________________________________________________________________________________ Relationship ______________________________________________________________________________

Eligibility Information
Name of Mother/Guardian __________________________ Highest Educational Level of Mother/Guardian Completed: 1-3 4-6 7-8 9 10 11 12 Bachelors Name of Father/Guardian __________________________ Highest Educational Level of Father/Guardian Completed: 1-3 4-6 7-8 9 10 11 12 Bachelors Masters Doctorate

Masters

Doctorate

Do you have a documented learning or other disability? Yes___No____ If yes, are you registered with the Lamar University Services for Students with Disabilities? Yes___No____ Does someone claim you as a dependent on their taxes? Yes___No____ If Yes, answer Section A. If No, answer Section B.
Section A: What is the size of your parents/guardians household, including yourself? __________ Did your parents/guardians file an income tax return for the previous year? Yes No If yes, what was their taxable income*? _________________. If no, place N/A on the line. *Taxable income can be found on Line 6 on 1040EZ / Line 27 on 1040A / Line 43 on 1040. Section B: What is the size of your household, including yourself, spouse and/or other dependents? _________ Did you file an income tax return for the previous year? Yes No If yes, what was your taxable income*? ______________. If no, place N/A on the line. *Taxable income can be found on Line 6 on 1040EZ / Line 27 on 1040A / Line 43 on 1040.

Income Verification: Please verify your taxable income by submitting a SIGNED COPY of your most recent tax return with this application. If you are claimed as a dependent on someone elses taxes, please submit a SIGNED COPY of their tax return as well.

Academic Assessment
Total Number of Semester Hours Prior to this Semester: _________________ How Many Hours Currently Enrolled In:______________________________ Major:_________________________ Minor:__________________________ Current College GPA: ___________ Interest in Graduate School: (Circle One of the Following) Yes No Undecided If answered undecided, please state why:__________________________________________________________ Hours Dedicated to Studying Per Day: ______________________________________ School Attendance: (Circle One of the Following) Full Time Part Time Work Status: (Circle One of the Following) Full Time Part Time Unemployed Has it been more than 5 years since you have been in school? Yes No Read the following statement and sign: I agree that the information on this application is correct to the best of my knowledge. If any information changes on this form while I am a part of this program, I will notify the Student Support Services immediately. I understand that in order for Student Support Services program to accurately assist me, I will be honest in communicating all my information that may be needed.

__________________________________________________________________________________________
Applicant Signature Date

Lamar University TRiO Student Support Services Release of Information

I, ______________________________________, authorize Lamar University TRiO Student Support Services (SSS) to gather information concerning my academic progress (standardized test scores, grade point average, earned credits, transcripts) and financial aid information prior to my participation and throughout my involvement in SSS. I understand that this information is used to assist in the determination of my eligibility for the SSS program and it will be held strictly confidential. I am aware that my eligibility, participation and financial aid status will be reported to the U.S. Department of Education in accordance with the grant funding regulations.

I certify that the information provided on this application is true and complete to the best of my knowledge. I also agree to provide documentation upon request to verify the information reported. I am aware that the personal information that is provided to the Student Support Services Program will be protected under the Family Education Rights Privacy Act of 1974. No one will have access to the information unless they work with or for the SSS Program, or they are specifically authorized by me to see the information.

Upon formal acceptance into the program, I grant permission for program representatives to have access to my official academic and financial records in order for SSS staff to assist me. Additionally, in the course of my involvement in the SSS program, SSS staff may consult with various Lamar University offices and programs to secure and share the necessary information pertinent to my participation in the program and overall collegiate success.

Finally, I give my permission to use photographs, quotes, and statements and/or print my first and last name in any and/or all publications for Student Support Services.

_________________________________________________________________________________ Signature Date

_________________________________________________________________________________ Parents Signature (for applicants under the age of 18)

Student Support Services Preliminary Needs Assessment

Below is a list of services available through Student Support Services. Please check any services you would find beneficial to your academic success. Academic Skills Time Management Study Skills Test Taking Test Anxiety Reading Speed Reading Comprehension Essay Writing Research Writing Critical Thinking Vocabulary Organization Proofreading Spelling Note Taking Basic Computer Skills Basic Math Skills (Developmental Math, College Algebra) Advanced Math Skills (Any Math course above College Algebra) Typing Peer or Group Tutoring Learning Strategies Other ___________________ Career Exploration Interest Testing/Career Choice Choosing a Major Career Information Academic Advising Resume Design Interviewing Job Search Graduate School Advising Other ___________________ Personal Assistance Goals and Decision Making Problem Solving Financial Aid Advising Personal Support Other ___________________

Can you think of anything that might keep you from completing your degree? (Family, grades, social life, money, self-motivation, career decision, other-please explain)________________________________________ __________________________________________________________________________________________

_________________________________________________________________________________ Signature Date