Add to SSS App Have You Ever Applied for ASU SSS
ASU Student Support Services Application
PO Box 1390 State University, AR 72467 (870) 972-2320 Fax: (870) 972-3060
Eugene W. Smith Hall, Room 301
Last Name: / First Name: / Middle:SS#
/ Student ID #: / Email:LOCAL
Street: State:
City: Zip:
Phone: Cell or Alt #: / PERMANENT
Street:
City: State:
Phone: Zip:
Date of Birth: / Major: Minor:
Gender: (MALE) (FEMALE) / Marital Status: (Married) (Single)
Ethnicity: ( ) Native American/Alaskan Native ( ) Hispanic or Latino ( ) Native Hawaiian or
( ) Asian ( ) White/non Hispanic Pacific Islander
( ) Black/non Hispanic ( ) More than one race ( ) Other
Referral: ( ) Brochure ( ) Faculty ( ) Upward Bound ( ) Newspaper ( ) Flyer
( ) Class ( ) Friend ( ) Booth ( ) Admissions ( ) Other
MOTHER: ( ) Unknown
( ) Did not graduate from High School
( ) GED ( ) 2 yr degree
( ) High school Diploma ( ) 4 yr degree
( ) Some College ( ) Other / FATHER: ( ) Unknown
( ) Did not graduate from High School
( ) GED ( ) 2 yr degree
( ) High school Diploma ( ) 4 yr degree
( ) Some College ( ) Other
Which type of financial aid do you receive?
( ) Veteran’s Benefits ( ) AR Rehabilitation
( ) College workstudy ( ) Loans
( ) Workforce One Stop ( ) SMART Grant
( ) Pell Grant ( ) I did not apply
( ) SEOG ( ) I am not eligible
( )Competitiveness Grant ( ) Other: ______/ Mark the services of greatest need to you: (May check more than one)
( )Academic advising ( ) Career advising
( )Tutoring ( ) Counseling
( )Study skills ( ) Mentoring
( )Computer lab ( ) Financial aid info
( )Graduate school help ( ) Cultural Enrichment
( )Resource Library
Do you have a disability?
( ) YES ( ) NO
Are you registered with ASU Disability Services?
( ) YES ( ) NO / If you have participated in TRIO Programs, please mark which one below:
( ) Upward Bound ( ) Talent Search
( ) SSS ( ) EOC
High school attended:
High school GPA:
Year Graduated: / College previously attended:
Dates attended:
Citizenship: ( ) US Citizen ( ) Territorial resident ( ) Permanent Visa ( ) Other
IMPORTANT: In order for your application to be complete, you must also submit
- Income Verification B. Autobiographical Statement C. Unofficial Transcript
Academic Readiness Self-Assessment
Please answer the following questions to the best of your knowledge. Your openness and honesty will help us
to evaluate how Student Support Services can best help you to reach your academic goals.
(SA) strongly agree (A) agree (I) indifferent (D) disagree (SD) strongly disagree
(SA) (A) (I) (D) (SD)(SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD) (SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD) (SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD) (SA) (A) (I) (D) (SD) (SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD) (SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD) (SA) (A) (I) (D) (SD) (SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD)
(SA) (A) (I) (D) (SD) (SA) (A) (I) (D) (SD) (SA) (A) (I) (D) (SD) / I enjoy college.
Personal issues make it hard to study.
I dread the thought of several more years of college.
I find it easy to make friends.
I am uncertain about my career goals.
I often have trouble concentrating.
Sometimes I feel I need more social and academic support.
I do not have adequate computer skills.
I know I will be a successful student.
When I take a test, I often forget what I studied.
I feel that I study all the time to no avail.
I seem to miss information that is presented in class.
I am reluctant to ask for help.
I have trouble finding the time to study.
I do not like to make decisions.
I feel that most teachers are caring.
My grades do not reflect my ability.
My grades are low because some of my professors are unfair.
Getting up the morning is difficult for me.
I know few people at ASU.
My family is very supportive of my decision to go to college.
I often worry about failure.
I avoid classes that require much reading.
I know where to find personal, financial, and academic support on campus.
My academic goal is ...
In order to reach this goal I must...
I, , wish to participate in the Student Support Services Program in order to achieve my educational goals. I agree to participate in all recommended services and will keep all scheduled appointments to help achieve these goals. I give SSS permission to secure any of my necessary academic and financial records to verify my eligibility for program participation. I agree that the information I provided on this application is true to the best of my knowledge.
SIGNATURE: DATE:
NOTE: The information requested in this form is used strictly to determine program eligibility as well as to provide program demographics to the Department of Education. ALL information will be kept in confidence by program staff. The ASU Student Support Services Program does not discriminate on the basis of ethnicity, gender, age, national origin or handicap.
Rev 4/11