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SHAWNEE STATE UNIVERSITY STUDENT SUPPORT SERVICES PROGRAM APPLICATION

All information you supply will be held in strict confidence.
This application cannot be considered if all information is not included.

SSU ID#  
First Name:     Middle Initial:     Last Name: 
Maiden/Former Name:                
Birth Date: 19   
Permanent/Parents Address:  
Number and street:    City:    State:    Zip: 
Local Address:  
Number and street:    City:    State:    Zip: 
Home Phone:      Local Phone:    Alternate Phone:    
Email Address: 
Dates you have lived in Ohio (you must choose one):
Birth to present From (month/year) To (month/year) Never
 

The information requested in the shaded area is used to report student and applicant demographic information to state and federal agencies.  Your completion of this area is completely voluntary.  This information will not be used for discriminatory purposes.*

Gender:

 
Marital Status: Single   Married   Divorced
 
Are you a US Citizen?  Yes   No
 

Race/Ethnic:      

(1) American Indian or Alaskan Native   

(2) Asian or Pacific Islander 

(3) African-American/Black

(4) Hispanic                       

(5) Caucasian / White
(6) Native Hawaiian or other Pacific Islander
 (7) More than one race reported   
   
Full Time Student(12+ Hours)

Part Time Student

 Day Student

Night Student

Declared Major:
*Shawnee State University does not discriminate in admission, access, or treatment in programs and activities or employment policies or practices on the basis of race, creed, sex, color, national or ethics origin, religion, marital status, age, sexual orientation, or qualified handicap.  Inquiries regarding Title IX may be directed to the Title IX coordinator, who is also the coordinator of special needs services, at 740-351-3276.
High School Attended: City:  State:
Did you graduate: Yes   No Year or Graduation: GPA:
Highest Degree Completed:  
Do you have a GED? Yes   No
List some college prep coursework you completed in high school:
What other schools other than SSU have you attended beyond high school?
School Name/Location Years Attended GPA Major
 
Who lives in your home?
Do you have children? Yes   No
If so, what are their ages?
Will child care be a problem? Yes  No
Did you apply for financial aid for the current school year?:  Yes  No
What type of financial assistance are you receiving?  Scholarship  Grant  Veteran's  Voc Rehab  CAO  Other  Loan  No Assistance
Dependency Status (as defined by Financial Aid):  Legally Dependent on own income  Legally Dependent on my parent's income
Note:  You MUST bring a copy of your latest tax form with you to the Intake Interview.
Taxable Household Income: $
Meets Guideline: Yes  No
(Staff Verification(Initial):  per  1040  1040A  1040EZ
What is the highest level of education COMPLETED by the parents you grew up with?
Mother:  Grade School  High School  2-Year College  4-Year College  Beyond 4-Year
Father:   Grade School  High School  2-Year College  4-Year College  Beyond 4-Year

Have you ever participated in any other TRIO programs?
Education Opportunity Ctr.  Talent Search  Upward Bound
Do you have any documented physical or learning disabilities?:  Yes  No
If yes, explain:
Are you currently being served by SSU's Special Needs Services?  Yes  No
Do you receive assistance from Vocational Rehabilitation?  Yes  No
What Obstacle(s) would most likely prevent you from completing your academic goals? (Check all that apply)
Poor Study Habits Bad Grades Family Medical Problems
Lack of Money Take things too seriously Separation or divorce
Taking the wrong classes Problems at home No close friends at SSU
Always feeling tired Trouble sleeping Recurring health concerns
Always worrying Afraid to speak up in class Alcohol and/or drug problems
Too shy Feeling depressed or sad No support from family/friends
Housing issues Transportation
How did you find out about the SSS Program?
Explain your reasons for applying to the SSS Program?
Check all the following services that may interest you and/or benefit you:
Counseling

Academic Advising/Degree Planning
 Financial Aid Application Assistance
 Career Counseling
 Career/Interest Testing
 Personal Counseling
 Peer Mentoring    

Transfer or Graduate School Planning

College Information
 College Application Assistance
 
Academic Support/Instruction
Tutoring in:
 Writing
 Sciences
 Math
 Other
 Calculator and cassette recorder check out
 Computer Access 		Workshops

Overcoming Test Anxiety
 Note-taking Tips
 Getting Organized
 ACT Preparation
 Stress Management
 Using Graphing Calculator (TI-85)
 Writing an Effective Paper
 Time Management
 Money Management
 Other:

If every space is not filled, this application will be rejected.

STOP!  You may stop here.   
Statement of Rights and Responsibilities


I will meet with a SSS Counselor at least twice per quarter.
I will apply for financial aid every year.
 I will attend classes regularly, and inform my instructors if absence from class is necessary.
I will check my mailbox at least every other week.
I agree to work with a tutor in any subjects I am getting a "C" or less.
I will meet with the appropriate SSS tutor at least five (5) times if I place into a Developmental Education class.
I understand that I am not eligible for SSS unless I agree to abide by the above requirements.

Student Publicity Release

I agree that if I am accepted into the Student Support Services Program, the staff may include my name and/or picture in publications, including their website.  This publicity highlights student accomplishments and participation in campus and SSS activities.

 

Release of Information

I certify that the information I have provided on this application is, to the best of my knowledge, complete and accurate.  Furthermore, I understand that by applying for the SSS Program, I authorize SSS staff to obtain records or data pertinent to my participation from other sources, and to release information to the United States Department of Education, TRIO programs.  The SSS staff also has my permission to communicate verbally or otherwise with staff, faculty, and/or off-campus professionals on my behalf.

 

NOTES:
Student Support Services at Shawnee State University does not discriminate on the basis of race, religion, color, national origin, sex, age, or disability with respect to access, employment programs, or services. 

I certify that the statements included in this application are accurate and true to the best of my knowledge. Any falsification of information may result in disciplinary action, including dismissal from the program.

Yes:                            No:

Name:          Date:

After we receive your application, you will be notified when to come in for your initial interview.

PERSONAL ACADEMIC INVENTORY
Name: Date:
Directions: Please read the following questions carefully. Answer each question as honestly as you can. This is NOT a test. If you have any questions about any of the following items, please request assistance before responding. For items 1-15, you will need to place only the number that corresponds to your response in the blank space provided at the extreme right side of the question.
1. How do you rate your ability to do well in courses that require good math skills?
1. Above average 2. Average 3. Below average 4. Inadequate
2. How do you rate your high school preparation in mathematics?
 1. Excellent  2. Good 3. Fair 4. Poor 
3. How do you rate your ability to do well in courses that require good reading skills?
1. Above average 2. Average 3. Below average 4. Inadequate
4. How do you rate your ability to do well in courses that require good writing skills?
1. Above average 2. Average 3. Below average 4. Inadequate
5. How do you rate your ability to write research papers, essays, etc.?
1.Good 2. Average 3. Below average 4. Inadequate
6. How do you rate your reading rate or speed of reading textbook material?
1.Good 2. Average 3. Below average 4. Inadequate
7. How do you rate your ability to do well on objective examinations  (True-False, Multiple Choice, Matching, etc.)?
1. Above average 2. Average 3. Below average 4. Inadequate
8. How do you rate your ability to do well on essay type examinations?
1. Above average 2. Average 3. Below average 4. Inadequate
9. How do you rate your ability to comprehend what you read in your college tests?
1. Above average 2. Average 3. Below average 4. Inadequate
10. How do you rate your present level of study skills and habits?
1. Above average 2. Average 3. Below average 4. Inadequate
11. Do you think you have the ability and skills to complete your college
requirements and earn the degree in the college major of your choice?
1. Very definitely yes 2. Probably, yes 3. Not sure 4. Probably, no
12. What grades do you think you are capable of earning in college?
1. Mostly A's 2. Mostly B's 3. Mostly C's 4. D's and C's at best
13. What grades are you currently earning in college? (If first semester freshman, answer according to high school achievement.)
1. Mostly A's 2. Mostly B's 3. Mostly C's 4. D's and C's
14. What grades do/will you attempt to earn at SSU?
1. A's  2. A's & B's 3. B's & C's  4. C's at best 
15. How do you rate yourself in general ability as compared to your classmates?
1. Superior 2. Above Average 3. Average  4. Below

Career Inventory
Declared Major: 
1. How sure are you at this point of your career goal?
1. Positively  sure 2. Somewhat sure 3. Not very sure 4. Undecided 
2. How sure are you that you have selected the major that you really want?
1. Positively  sure 2. Somewhat sure 3. Not very sure 4. Undecided 
If you marked 3 or 4 for the above questions, would you be willing to:
     
Complete career testing? Yes No:
Talk to a Career Counselor? Yes: No:
Enroll in Career Planning class (PSYC 105)? Yes: No:

If you have any questions about this on-line application process, please contact us via email 
at dschwamberge@shawnee.edu.

 
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Portsmouth, Ohio 45662-4344
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TTY: 740.351.3159

Last Updated:
09.01.2009 10:59 AM

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