Student Support Services Form
Dear Student and family,
In the Academic Resource Center we have a program called Student Support Services (SSS). This program is funded by federal dollars and provides outreach to students to help with their college adjustment. The goal of SSS is to encourage student success and assist in the connection to life at Viterbo University.
The program is limited to 200 students who: are first generation (meaning neither parent has a four year college degree); have a family income below an amount the federal government designated or have a diagnosed disability. You need to fit only one of the criteria.
While a large percentage of our students meet one of the categories, the program is limited to approximately 70 freshmen. An attraction of this program is that you may receive free tickets to events in the Fine Arts Center.
ALL families should complete this form (2 pages) and send back. Even if you don’t qualify, please designate N/A, sign and return. Federal income guidelines indicate that a family of four with TAXABLE income less than $35,000 are deemed eligible for this program. Please note that I will need the family’s taxable income for 2014 found on Line 43 on the 1040 tax form (NOT adjusted gross which is reported on the FAFSA) AND the number of individuals in your household claimed on tax forms. All information is confidential.
Once you arrive on campus in fall you will be notified if you have been chosen for the Student Support Services program and you will be invited to meet with a staff member in the Academic Resource Center. Our hope is to establish a relationship with you and assist in your college success and adjustment.
Questions? Please call me at 796-3194 or email . We look forward to working with you.
Regards,
Jane Eddy, Director
Academic Resource Center and Student Support Services
If the student is on a parent’s tax return, provide information about parent’s income. If financial aid is based solely on student’s earnings, provide student’s taxable income.
Student’s name: Click here to enter text.
Did either parent graduate from college with a Bachelor’s Degree (this does not include a technical or two year degree)? Choose an item.
Family’s taxable income for 2014 (line 43 on 1040): Click here to enter text. # of exemptions: Click here to enter text.
Signature of person who filed tax return ______
Parent email address: Click here to enter text.
Proposed Plan of Involvement in
Student Support Services (SSS) Program Choose an item.
Please provide the requested information. Student’s electronic signature must be placed on the bottom of this form.
Student’s Name: Click here to enter text.
Cell Phone #: Click here to enter text.
The following information indicates my proposed plan of involvement in Student Support Services:
- As the need arises, I will seek support in these areas: (click on all that apply)
☐Reading (comprehension, recall, speed, vocabulary)
☐Writing (classes, idea generating, thesis development, editing, grammar, spelling)
☐Mathematics
☐ESL (English as a second language)
☐Workshops
☐Tutoring in specific courses
☐Graduate School Preparation
- As the need arises, I will utilize the following counseling services: (click on all that apply)
☐Academic (study skills, note-taking, time management)
☐Career (resumes, job search, interest inventories)
☐Personal (stress, loneliness, depression, homesickness, relationship issues)
- I will participate in the cultural aspect of the program, which entitles me to free tickets at the Fine Arts Center
☐Yes
☐No
As a member of SSS, I agree to meet with my assigned academic counselor in the Academic Resource Center.
Click here to enter text.Click here to enter a date.
SignatureDate
The information on this form is for Academic Resource Center use ONLY. SSS plan of involvementRevised 3/15