Waitlistparticipant Application

WAITLISTParticipant Application

PERSONAL INFORMATION
First Name: / M.I.: / Last Name:
Have you attended A&M-Texarkana under any other name?
If you so, please list them: / Student ID:
Date of Birth: / Soc. Sec. Number:
Street Address:
City: / State: / Zip:
Mailing Address:
City: / State: / Zip:
Phone (Home): / Cell: / Work:
Email Address:
Are you a US Citizen? Yes No / Resident Number: / ______
Gender:
Male
Female / Are you now or have you ever been in foster care?
Yes No / Are you now or have you ever been homeless?
Yes No
Ethnicity: Mark all that apply. / Eligibility:
Black/African American
Native American
Hawaiian/Pacific Islander
Hispanic/Latino
Alaskan Native
White
Asian
Multi / Did your father graduate from a 4-year college/university?
Yes No
Did your mother graduate from a 4-year college/university?
Yes No
Do you have a documented disability?
Yes No
Do you receive a Pell Grant (Financial Aid)? Yes No
What is the number of persons in your immediate household? ______
What is your family’s total taxable income? (Please Check One)
$00.000 to $17,655 $17,656 to $23,895 $23,896 to $30,135
$30,136 to $36,375 $36,376 to $42,615 $42,616 to $48,855
$48,856 to $55,095 $55,096 to $61,335 $61,336 and over

Consent Statement

Signature: ______Date: ______

I hereby consent to the release of my academic and financial aid record/information to the Texas A&M-TexarkanaTRIO Student Support Services Program. I hereby certify that all information contained herein is accurate. I give permission to the Texas A&M-TexarkanaTRIO SSS Program to secure my academic/financial information from appropriate Texas A&M-Texarkana sources in order to provide the services that I am requesting.

Name______PERSONAL EDUCATION PLAN (PEP)

SHORT-TERM
GOAL: / MY DEGREE/CERTIFICATE OBJECTIVE: (See A&M-Texarkana’s2014-2015 catalog DEGREE AND CERTIFICATES pages 56-57)
Bachelor of Arts Degree / Major:
Bachelor of Applied Arts & Sciences Degree / Major:
Bachelor of Business Administration Degree / Major:
Bachelor of Science Degree / Major:
Undecided / Classification Freshman Sophomore Junior Senior
LONG-TERM GOAL: / Bachelor’s Degree
Master’s Degree
Specialist’s Degree (EdS, PsyD, etc.)
Doctoral Degree (PhD)
Professional Degree (JD, MD, DDS, etc.) / Please briefly describe your career goals:
SERVICES REQUESTED: (CHECK ALL THAT APPLY)
ACADEMIC SUPPORT / TRANSFER SUPPORT / SOCIAL/CULTURAL SUPPORT
Tutoring
Computer Lab
Academic Workshops
Study Skills
Test Anxiety
Time Management
Other: / Do you plan to transfer to another 4-year college/university? Yes No
Campus/Transfer Visitation:
U of A Texas A&M University-Commerce
SAU UALR
Other: ______/ TRIO Student Success Club
Cultural Awareness (Activities, Events, and Trips)
Social Workshops
Stress Management
Self-esteem Awareness
Other: ______

PARTICIPANT AGREEMENT CONTRACT

I accept this opportunity to participate in the Texas A&M University-Texarkana’s TRIO Student Support Services Program. I understand the goals of this program are to retain and graduate eligible Texas A&M University-Texarkana students. I further understand that selection as a participant of the Texas A&M University-Texarkana TRIO Student Support Services Program is a privilege.

I understand and agree to the following terms of the Texas A&M-Texarkana TRIO Student Support Services Program. Please read and initial each statement below.

I will utilize TRIO SSS Services.
I will meet with my Educational Specialist/Coordinatorat least three times each semester.
I will complete the Financial Literacy requirements.
I do hereby agree to the conditions stated in this PARTICIPANT AGREEMENT CONTRACT.
______
Participant’s (Printed) Name Participant’s Signature Date (mm/dd/yy)
The TRIO SSS Program funded in total (100%) by federal grant funding from the U.S. Department of Education, with an annual budget of $220,000.

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