OMNI STUDENT SUPPORT SERVICES PROGRAM APPLICATION

PLEASE SEND YOUR APPLICATION TO:
Student Support Service
OMNI State College
P.O. Box 443086
Pleasantville, NY 30471

PART I: APPLICANT INFORMATION

Name:
Last / First / Middle
Social Security #: / OMNI Student ID: / Date of Birth:
Local Address:
Street / P.O. Box / City, State, Zip
Permanent Address:
Street / P.O. Box / City, State, Zip
Telephone #:
Local / Emergency with (area code)
Email Address:
School / Other
Gender: / Female / Male
Ethnic Heritage: / African American / Caucasian / American Indian
Asian American / Chicano/a Latino/a / Alaskan Native
Other (identify)
Citizenship: / US Citizen / Permanent Resident / #
PART II: ACADEMIC INFORMATION
Are you registered for classes at OMNI State College? Yes No Are you a transfer student? Yes No
Major: / Academic Advisor:
Minor: / OMNI Cum GPA:
Year in School: / Sophomore / Junior / Senior
Year you plan to graduate
Do you plan to receive a degree? / Yes No If so, what degree:
Where did you go to high school?
Did you graduate? Yes No / If yes, what year?
If no, did you receive a GED? Yes No / Have you participated in any other TRIO program? Yes No
Referred to SSS by: / Upward Bound Talent Search Other SSS
When?

How can we help you complete this Degree? (check all that apply)

Academic Skills: Career Development Skills:

Time Management Interest Testing/Career Choice

Study Skills Choosing a Major

Test Taking Career Guidance

Reading Speed Academic Advising

Reading Comprehension Resume Design

Essay Writing Interviewing

Research Writing Job Search

Critical Thinking Career Information

Vocabulary

Organization Personal Assistance:

Proofreading

Spelling Peer Mentoring

Note Taking Goals/Decision Making

Basic Computer Skills Problem Solving

Basic Math Financial Aid Advising

Finite Math

Algebra

Test Anxiety

Typing

Peer or Group Tutoring

Learning Strategies

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)

PART III: FAMILY INFORMATION

The information below, which must be provided by all applicants, is used to determine applicant’s eligibility for the Student Support Services Program and will be treated confidentially. Last year’s Income Tax Return must be returned along with the application.

Name of Mother/Guardian:
Highest Level of Schooling Completed:
Elementary Level (grade 1-6) / Associate’s Degree
Secondary Level (grade 7-12) / Bachelor’s Degree
Some College, No Degree / Master’s Degree
Name of Father/Guardian:
Highest Level of Schooling Completed:
Elementary Level (grade 1-6) / Associate’s Degree
Secondary Level (grade 7-12) / Bachelor’s Degree
Some College, No Degree / Master’s Degree
If you are from a single-parent household and lived with a parent prior to the age of 18 and that parent did not receive a four-year degree, check here.
If, prior to the age of 18 you did not live with or receive support from a natural or adoptive parent and are considered an orphan or ward of the court, check here.
For financial aid purposes, are you considered dependent or independent?
If dependent, complete Section A / If independent, complete Section B
What is the size of your parents’/guardians’ household, including yourself?

Did you or your parents file a federal income tax return for 2003? yes no
If yes, what was their 2003 taxable income?
(IRS Form 1040–Line 40; IRS Form 1040A–Line 27; IRS Form 1040EZ–Line 6)
If no, place a “0” on line for taxable income.
(Submit your parent/guardian’s income tax return) / What is the size of your household, including yourself, spouse, and/or other dependents?

Did you, or will you, file a federal income tax return for 2003? yes no
If yes, what was your 2003 taxable income?
(IRS Form 1040–Line 40; IRS Form 1040A–Line 27; IRS Form 1040EZ–Line 6)
If no, place a “0” on line for taxable income.
(Submit your personal income tax return)

PART IV: AUTHORIZATION AND AFFIRMATION

THIS APPLICATION MUST BE SIGNED BEFORE SUBMITING

1.  I hereby authorize the OMNI Student Support Services Program Staff to obtain academic, financial aid and other information pertinent to my participation in the Student Support Services Program at the OMNI.

2.  I understand that a copy of my application form will be kept on file at the Student Support Services Program Office and that the resulting information received from counselors, admission and financial aid officers, instructors, etc. will be kept confidential in compliance with the Family Rights and Privacy Act.

3.  I affirm to the best of my knowledge that the information I have provided is true.

Signature / Date

9dii2 Application Sample