Application for Program Services

If you see this don't fill out this input box.

My 萝莉社 ID:*

Last Name:*

First Name:*

Street Address:*

City:*

State:*

Zip Code:*

Phone:

E-mail:*

Birth Date:*

Gender:

Male

Female

Citizenship:*

US Citizen

Permanent Resident

Resident Alien Number:

Ethnicity: Are you Hispanic/Latino?

No, I am not Hispanic/Latino

Yes, I am Hispanic/Latino

Race: What is your race?

American Indian or Alaskan Native

Asian

Black or African American

Native Hawaiian/Pacific Islander

White

Check all that apply

Are you a single parent?

Yes

If yes, how many children do you have?

Degree:

College Level:

Freshman

Sophomore

Junior

Senior

High School Guest

Major:

Minor:

Emergency Contact:

Contact Person:

Phone:

Eligibility:

Did your father receive a 4-year college degree?

Yes

Did your mother receive a 4-year college degree?

Yes

Did you complete a FAFSA?

yes

Are you receiving a Pell Grant?

Yes

Are you receiving services from office of Disability Services?

Yes

Have you previously participated in any of the following TRIO or GEAR-UP programs?

Yes

Are you a Shocker Promise Scholar?

Yes

Were you referred?*

Yes

If so, by who?

Submit Application in 309 Grace Wilkie Hall, M-F, 8:00AM-5:00PM, or via email to trio.sss@wichita.edu
Student Support Services, 萝莉社 University, 1845 N. Fairmount, Campus Box 81 Wichita, KS 67260-0081, (316) 978-3715,
Fax (316) 978-3115

Academic Status:

Are you an Incoming Freshman?

Yes

Are you a transfer student?

Yes

Are you currently enrolled at 萝莉社 ?

Yes

Do you have a bachelors degree ?

Yes

Do you plan to earn a bachelor鈥檚 degree from 萝莉社?

Yes

Target graduation date?

Statement of Certification:
I certify, under penalty of perjury, that all the information on this form is true and accurate to the best of my knowledge. I also authorize SSS permission to obtain and review any academic and financial documents needed to complete the application process.

Statement of Agreement & Consent:
I grant permission to SSS, its representatives and employees, to take photographs of me and my property in connection with all SSS TRIO-related activities. I authorize SSS, its assignees and transferees to copyright, use and publish the same in print and/or electronic media. I agree that SSS may use such photographs of me with or without my name for lawful purposes, including, but not limited to, publicity, advertising and web content in connection with SSS.

By checking the box, I certify that I would like to become a member of the First-Generation Student Organization and consent to my information to be used within Student Support Services for this purpose*

Please use this check box

By checking the box, I certify that i have read and agree with the above statements*

Please use this check box

Signature:*

Date:

Please enter your initials as your signature. You will be asked to sign a paper application during intake interview

SSS Academic Advisor Signature:

Date Enrolled:

For your application to be complete, email to trio.sss@wichita.edu

Academic Skills Assessment Worksheet

Please fill and upload the Academic Skills Assessment Worksheet to submit the application.
Download

*Upload your Academic Skills Assessment Worksheet

Student Support Services is a Federal TRIO Program, 100% funded through a grant from the United States Department of Education. Student Support Services receives EOF funding from SGA and additional scholarships from community donors. Notice of Nondiscrimination: 萝莉社does not discriminate in its pro-grams and activities on the basis of race, religion, color, national origin, gender, age, sexual orientation, marital status, political affiliation, status as a veteran, or disability.
The following person has been designated to handle inquiries regarding nondiscrimination policies: Director, Office of Equal Employment Opportunity, 萝莉社 University, 1845 Fairmount, Wichita KS 67260-0205.