Student
Support Services Application
Submit applications to Student Support Services: 2131 Centennial Hall or Fax: 608-785-8532.
If you have any questions, call 608-785-8535
STUDENT INFORMATION
First Name:
Last Name:
Preferred
Name:
M.I.:
SS #: --
Student ID #:
Campus or Local Address:
City:
State:
Phone Number:
Date of
Birth:
Zip Code:
UWL Email:
Permanent Address:
City:
Gender:
PGPs:
Zip Code:
State:
Male
He/Him/His
Residency:
Ethnicity:
Transgender
Female
She/Her/Hers
U.S Citizen
Non-Binary
Self-Identifying
Per/Per/Pers
They/Them/Theirs
Self-Identifying:
Permanent Resident/Resident Alien #:
Veteran
Native American/Alaska Native
Black/African-American
Asian
Hispanic/Latino
Native American/other Pacific Islander
Caucasian
Multi-Racial (Specify):
ACADEMIC INFORMATION
Have you ever been a TRIO participant?
If yes, indicate which program(s):
Student Support Services
Educational Opportunity Center
What is your class standing?
Yes – Location:
Talent Search
No
Upward Bound
Other (specify):
0-29 Credits (First Year)
60-89 Credits (Junior)
30-59 Credits (Sophomore)
90+ Credits (Senior)
1
Major/Academic Interests:
What are your long term educational goals?
Bachelor’s Degree
Master’s Degree
Doctorate Degree
How did you learn about the Student Support Services TRIO Program/who referred you?
Which SSS services are you interested in receiving?
Are you receiving any services from another office?
Yes (specify):
No
ELIGIBILITY INFORMATION
FIRST GENERATION STATUS
What is the highest educational level completed by your parents (check one for each) or legal guardian?
Mother
Father
OR Legal Guardian
Did not complete High School
High School Diploma or GED
Some College
2-Year Degree
Bachelor’s Degree or higher
DISABILITY STATUS
Do you have a learning disability?
Yes
No
Do you have a physical disability?
Yes
No
Your disability must be recognized by the UW-La Crosse Access Center in 165 Murphy Library. If you are currently
registered with the Access Center, who is your advisor from that office? Advisor:
HOUSEHOLD FINANCIAL INFORMATION
Have you applied for Financial Aid?
Check all that apply:
Pell Grant
Yes
No
Work-Study
If yes, were you awarded Financial Aid?
Scholarships
May this office have access to your financial aid file to verify SSS eligibility?
Loans
Yes
Yes
No
Other:
No
2
INDIVIDUAL NEEDS ASSESSMENT
Check all that apply to you:
Academics
Unsure high school prepared me for college
Achieved a GED
Concerned about my math skills
Concerned about my writing skills
Concerned about my science skills
Unaware of my learning style
Inexperienced with study strategies that work for me
It’s been more than 5 years since I have been in school
Poor study habits
I have a documented disability
Afraid of failing a course in college
Major/Career
Don’t know which major would be a good fit for me
Have a lot of interests but can’t seem to pick one
Inexperienced in selecting a major or career
Decided on a major but not sure I'm prepared to succeed in it
Not sure what type of job I can get with my degree
Personal
Plan to work over 20 hours a week and go to school full time
Significant family responsibilities (children, siblings, spouse, parents, etc...)
Significant financial responsibilities outside of school costs
Entering college as a non-traditional student
Not sure if college is right for me
English is a secondary language for me
Difficulty meeting deadlines
Lack of support from family and friends
3
AGREEMENT TO PARTICIPATE
If accepted to participate in Student Support Services,
 I agree to meet with my SSS Advisor at least two times a semester
 I agree to be honest and conscientious with my SSS Advisor and use the services of SSS to help me be a
successful college student
 I agree to attend at least one SSS workshop of academic enhancement each semester
 Please check one:
I give my consent for the University of Wisconsin-La Crosse Student Support Services program to use my
photo and provide information on my participation in the SSS program on the SSS website, brochures and
newsletters. This agreement remains in effect during my years as a UWL student.
I do not give consent for UWL Student Support Services to use my photo
I certify that the information I have provided on this application is, to the best of my knowledge, complete and
correct. Furthermore, I understand that by applying for the TRIO Program, I authorize program staff to obtain records
or data pertinent to my participation from other sources and to release information, as required by law or the terms of
the Student Support Services grant, to the grant-funding agency of the United States government. The Student
Support Services program staff has permission to communicate verbally and otherwise with staff, faculty, and/or
off-campus professionals on my behalf.
Signature:________________________________________________ Date:________________
Student Support Services is funded by the U.S. Department of Education. Acceptance into the program is contingent
upon meeting eligibility criteria and space available.
Your application will be reviewed, and you will be notified by email of your eligibility status. 4