Student Support Services

Intake/Application Form
*Fields in Red are Required
*Today's Date  
*First Name  MI  *Last Name
SSN  Birthdate  
E-mail Address
Maiden Name

Address (while attending C.C.)
Street  City  State
Zip  Phone  Cell Phone

Address (permanent)
*Street  *City  *State
*Zip  Phone

Ethnic group:
American Indian

Hispanic American

 African American
Caucasian Asian_American Native Hawaiian or other Pacific Islander
Other    

Gender:
Male Female

U.S. Citizen Yes No
If not a U.S citizen are you a permanent resident? Yes No
Are you eligible for federal financial aid? Yes No

Marital Status:
Married Single Divorced

Have you completed your FAFSA for this academic year? Yes No
Are you currently employed? Yes No  Hours per week
How did you learn about the SAIL program?


Educational Background
High School Attended  City  State
Year Graduated/GED  Graduating Class Size  
GED Yes No   Score
Are you currently enrolled at Crowder College? Yes No
Total number of college hours completed  Cumulative G.P.A.
List other colleges you have attended.

Educational Goals
Transfer without AA/AS degree   AA,AS, or AAS degree only
No degree sought   Transfer with AA/AS degree   Uncertain
Anticipated Graduation Date
Crowder College Major
If transferring, what colleges are you considering?



Eligibility
 Did either parent earn a 4 - year degree? Yes No
Do you have a disability which will affect you academically? Yes No
NOTE: If you qualify for SSS program due to a disability, you must have documentation on file in the Crowder College Office of Disability Services.

Total Number in Household
Total taxable income for (previous year)  was
All forms of income and sources of support must be reported to document income eligibility for the Student Support Services program. Without complete information your application for services will be denied.

Academic Need
Please check all that apply
My high school GPA was less than 2.5
My high school graduation class had less than 100 members
My high school did not have, or I did not participate in, college prep coursework
I was under an IEP in high school
English is my second language
I am currently a single parent
It has been at least 5 years since I've been in school
I am unsure what I want to major in
I am going through an enternal funding agency (VR, TRA, PIC, DFS...)
I have participated in a TRIO program

I certify that the above statements are true, and hereby, authorize Student Support Services / SSS to obtain copies of my admissions records and financial aid information for program purposes.
Name  Date
In the absence of a written signature, if you agree to the above terms, please select the SUBMIT button.

In order to determine your eligibility for the SSS program, all fields will have to be completed either online or with a staff member.