Student Application

Student Support Services (SSS), a TRIO program funded by the U.S Department of Education, provides access and support to students who are first generation, meet federal income guidelines, and/or who have disabilities. Our goal is to retain and graduate students, while fostering academic success and promoting personal growth.

Services Provided:

Student Support Services offer a wide variety services such as academic counseling, tutoring, peer-mentoring, workshops, mental health resources, financial literacy, graduate school preparation, career services, and finacial aid including helping students with the FAFSA.

Mentoring Program:

Mentor groups will meet frequently throughout the year, attending and participating in a wide variety of cultural, social, and academic programs. As an added benefit, participants who successfully complete the peer coaching, along with general program requirements, may be eligible for an SSS Scholarship.

Tutoring:

Student Support Services provides free one-on-one tutoring for all its participants. Students and tutors meet whenever their schedules permit.

Questions? Please call (719) 587-7632 or email: sss@adams.edu

To determine eligibility, please complete this form. The information provided is strictly confidential. This information is required because this is a federally funded program and students who wish to participate must meet certain requirements

Name*

First NameLast Name

Email*

example@example.com

Social Security Number (SSN)*

Copy of SSN card *

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.

Date of Birth*

Date

Copy of ID*

Assigned Birth Sex*

MaleFemale

Ethnicity/Race*

Parent/Guardian Full Name*

First NameLast Name

Parent/Guardian Phone Number *

Please enter a valid phone number.

Is your Parent/Guardian's address different than yours*

YesNo

Enter other address here

Emergency Contact Relationship *

Emergency Contacts Name*

First NameLast Name

Cell Phone Number*

Please enter a valid phone number.

Does your emergency contact have the same address as you?*

YesNo

Enter other address here

Citizenship*

Resident Alien Number

Father's Education*

Mother's Education*

Do you have a disability that is, or can be, documented through Adams State University Disability Services?*

YesNo

Are you registered with Vocational Rehabilitation?*

YesNo

Have you been diagnosed with a learning disability?*

YesNo

Have you been diagnosed with a physical disability?*

YesNo

Tax Form*

Parent's Taxable Income

Student's Taxable Income

Number of People in the Household listed on your FAFSA*

Enrollment*

From Where?

Enrollment Status*

College Grade Level*

Current or High School GPA*

College Major*

Minor*

Do you expect to graduate from ASU within 6 years?*

YesNo

Why?

Are you a non-traditional student (over 24 years of age or out of school for longer than five years)?*

YesNo

Have you participated in any TRIO programs? (check all that apply)

EOCSSSTSUB

Academic Needs (check all that apply)*

I certify that all information I have provided is true and correct to the best of my knowledge. I authorized Adams State University and Student Support Services staff to use the data provided in this application in assessing any academic and/or career-planning needs.

By signing this form, I understand that all information will be kept strictly confidential

Parent's/Contributor's Signature (for parent's/contributor's taxable income only)

Student Signature*

Date*

Date

Student Application

Adams State University Student Support Services

Parent/Guardian Information

Emergency Contact Information

Eligibility

Disability

Tax Information

Academic Information

Release of Records