WAITLIST Participant 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:
Are you now or have you ever been in
Are you now or have you ever been
Male
foster care?
homeless?
Female
Yes
No
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
I hereby consent to the release of my academic and financial aid record/information to the Texas A&MTexarkana TRIO Student Support Services Program. I hereby certify that all information contained
herein is accurate. I give permission to the Texas A&M-Texarkana TRIO 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.
Signature: ________________________________________Date: ________________________
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.
PY 16-17
WAITLIST Participant Application
Name____________________________________ PERSONAL EDUCATION PLAN (PEP)
SHORT-TERM
GOAL:
Bachelor of Arts Degree
Bachelor of Applied Arts &
Sciences Degree
Bachelor of Business
Administration Degree
Major:
Bachelor of Science Degree
Major:
LONG-TERM
GOAL:
MY DEGREE/CERTIFICATE OBJECTIVE: (See A&M-Texarkana’s 2014-2015 catalog
DEGREE AND CERTIFICATES pages 56-57)
Undecided Classification
Freshman Sophomore
Junior
Senior
Bachelor’s Degree
Please briefly describe your career goals:
Master’s Degree
Specialist’s Degree
(EdS, PsyD, etc.)
Doctoral Degree (PhD)
Professional Degree
(JD, MD, DDS, etc.)
Major:
Major:
SERVICES REQUESTED: (CHECK ALL THAT APPLY)
ACADEMIC SUPPORT
Tutoring
Computer Lab
Academic Workshops
Study Skills
Test Anxiety
Time Management
Other:
TRANSFER SUPPORT
SOCIAL/CULTURAL SUPPORT
Do you plan to transfer to another 4TRIO Student Success Club
year college/university?
Yes
No
Cultural Awareness (Activities,
Campus/Transfer Visitation:
Events, and Trips)
U of A
Texas A&M UniversitySocial Workshops
Commerce
Stress Management
SAU
UALR
Self-esteem Awareness
Other: _____________________
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/Coordinator at 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)
For Official TRIO SSS Office Use Only
Academic Need Code ______BANNER Attribute Code _____ Blumen Input _____Pell Verification _____TRIO SSS Staff ______
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.
PY 16-17