Saint Louis University

Student Support Services Application

You may complete this application by mailing a copy to:

Student Support Services

O’Brien Hall

3745 West Pine Mall

St. Louis, MO 63108

Or by emailing a copy to:

Part I: Applicant Information

Name: / ______/ ______/ ______
Last / First / Middle
Banner ID: / ______/ Date of Birth: / ______
SLU Email: / ______/ Cell Phone: / ______

Have you participated in any other TRIO programs? Yes No

If yes, check all that apply:  Upward Bound Talent Search SSS

How did you learn about SSS? ______

Part II: Academic Information

Major / ______/ Academic Advisor / ______
Minor / ______/ SLU Cum. GPA / ______
Year in School: / Freshman (0-29) / Sophomore (30-59) / Junior (60-89) / Senior (90+)
Cumulative Credit Hours / ______/ Year you plan to graduate: / ______

Are you a transfer student?  Yes No

Are you registered, or do you plan to register, with disability services?  Yes  No

In what areas do you feel you need to grow/develop? (Check all that apply)

Academic Skills / Career Development Skills
Time Management / Interest Testing/Career Choice
Study Skills / Choosing a Major
Test Taking / Career Guidance
Note Taking / Resume Design
Learning Strategies / Interviewing
Reading Speed / Job Searching
Reading Comprehension / Career Information
Essay Writing / Salary Negotiation
Research Writing / Graduate School Information
Vocabulary / Faculty/Career Mentoring
Organization
Proofreading / Life Skills
Spelling / Peer Mentoring
Basic Computer Skills / Goals/Decision Making
Basic Math / Problem Solving
Finite Math / Financial Literacy
Algebra
Academic Advising

Updated 6/1/2018

Can you think of anything else that might keep you from completing your degree?

______

Part III: Family Information

Parent/Guardian Name: / ______
Highest Level of Schooling Completed
 Elementary Level (grades 1-5) /  Associate’s Degree
 Secondary Level (grades 6-12) /  Bachelor’s Degree
 Some College, No degree /  Graduate Degree
Parent/Guardian Name: / ______
Highest Level of Schooling Completed
 Elementary Level (grades 1-5) /  Associate’s Degree
 Secondary Level (grades 6-12) /  Bachelor’s Degree
 Some College, No degree /  Graduate Degree

 Check here 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 a ward of the court.

Part IV: Financial Aid Information

Please complete the attached form providing your parent’s2016taxable income and family size [If you are an independent student, you may use your information instead of your parent’s]. Your taxable income can be found on line 43 of Form 1040, line 27 on Form 1040A, and line 6 on Form 1040EZ.

Part V: Essay

Please address the following two questions (you may use additional pages as needed):

  1. Why would you like to be a participant in the TRIO Student Support Services Program?
  2. What will you do in the program to be an active participant and a successful college student?

______

Part VI: Authorization and Affirmation

This application must be signed before submitting

  1. I hereby authorize Saint Louis University TRIO-Student Support Services program staff to obtain academic, financial aid and other information pertinent to my participation in the TRIO-Student Support Services program. I also authorize the Saint Louis University TRIO-Student Support Services program staff to verify whether or not I am registered with Disability Services at Saint Louis University (no details regarding the disability/medical documentation will be shared, simply the registration status and accommodations).
  2. I understand that a copy of my application will be kept on file at the TRIO-Student Support Services program office and that the resulting information received from advisors, admissions, financial aid, instructors, etc., will be kept in compliance with the Family Education Rights and Privacy Act.
  3. I understand that submission of an application to join Saint Louis University TRIO-Student Support Services does not guarantee my admission into the program.
  4. I affirm to the best of my knowledge that the information I have provided is true and correct.

Signature: ______Date: ______

For Office Use Only

Eligibility: / FG Only / LI Only / FG & LI / D only / D & LI
Academic Need: / ______
Admitted: / Yes / No / SSS Advisor: / ______
Authorizing Signature: / ______/ Date: / ______

This document verifies the 2016 taxable income for the family of the student listed below. Please make sure to include your taxable income as that is often lower than the adjusted gross income listed on the FAFSA. You can find your taxable income on your 2016 federal tax forms. It is located on line 43 of Form 1040, line 27 on Form 1040A and line 6 on Form 1040EZ. You do not need to include any tax data. Self-reported data in the lines below is sufficient

Please know that this form will be kept in the student’s file and will be kept confidential in compliance with the Federal Education Rights and Privacy Act (FERPA).

Student Name: ______(please print)

Student ID: ______

2016 Parent* Taxable Income: ______

Family Size: ______

I affirm that to the best of my knowledge the information provided above is true and correct. I understand that misrepresentation of the facts above will be cause for refusal of admission or dismissal from the Saint Louis University TRIO-Student Support Services program.

______

Parent Signature**Date

______

Student SignatureDate

*If you are an independent student use your taxable income.

**If you are an independent student you do not need to sign this line.

Updated 6/1/2018