Saint Louis University
Student Support Services Application
You may complete this application by submitting this hard copy to:
Student Support Services
O’Brien Hall, room 200
3745 West Pine Mall
St. Louis, MO 63108
PART 1:
APPLICATION INFORMATION
Name:
_________________________
Last
_________________________
First
Banner ID:
_________________________
Date of Birth: ______________
Email Address:
_________________________
SLU Email
Cell Phone: _______________
PART II:
_________________________
Middle
ACADEMIC INFORMATION
Major:
_________________________
Academic Advisor:
_________________________
Minor:
_________________________
SLU Cum GPA:
_________________________
Year in School:
 Freshman (0-29)
Cumulative Credit Hours:
_________________________
Are you a transfer
student?
Do you plan to receive a
degree from SLU?
 Yes
 No
 Yes
 No
Have you participated in
any other Trio program?
If Yes, check all that
apply
 Yes
 No
Referred to SSS by:
___________________________________________
 Upward Bound
 Gear Up
 Sophomore (30-59)
 Junior (60-89)
Year you plan to
graduate:
 Senior (90+)
_________________________
If Yes, what degree:_________________________________________
 Talent Search
 SSS
Year:______________
Are you registered with disability services or do you plan to register with disability services?  Yes
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 No
Updated. 01/05/2016
How can we help you complete this Degree? (Check all that apply)
Academic Skills:
Career Development Skills:
 Time Management
 Study Skills
 Test Taking
 Note Taking
 Test Anxiety
 Learning Strategies
 Reading Speed
 Reading Comprehension
 Essay Writing
 Research Writing
 Vocabulary
 Organization
 Proofreading
 Spelling
 Basic Computer Skills
 Basic Math
 Finite Math
 Algebra
 Peer or Group Tutoring
 Other _________________________
 Interest Testing/Career Choice
 Choosing a Major
 Career Guidance
 Academic Advising
 Resume Design
 Interviewing
 Job Search
 Career Information
Life Skills:
 Peer Mentoring
 Goals/Decision Making
 Problem Solving
 Financial Literacy
Can you think of anything else that might keep you from completing your degree? ______________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
(family, grades, social life, money, self-motivation, career decision, other, please explain)
Information in Part II & III, must be provided by all applicants. This is used to determine your eligibility for the Student
Support Services Program and will be treated confidentially.
PART III: FAMILY INFORMATION
Name of  Mother/ Guardian: _______________________________________________________________
Highest Level of Schooling Completed:
 Elementary Level (Grade 1-6)
 Associate’s Degree
 Secondary Level ( Grade 7-12)
 Bachelor’s Degree
 Some college, No degree
 Master’s Degree
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Name of  Father/ Guardian: _______________________________________________________________________
Highest Level of Schooling Completed:
 Elementary Level (Grade 1-6)
 Associate’s Degree
 Secondary Level ( Grade 7-12)
 Bachelor’s Degree
 Some college, No degree
 Master’s Degree
 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 ward of the court, check here.
PART IV: FINANCIAL AID INFORMATION
Have you (or will you) completed the 2016-17 FAFSA?
Yes
No
If yes, please provide a signed copy of the Student Aid Report (SAR) along with this completed application.
The SAR is the processed FAFSASM results you receive after applying for federal student aid.
If you cannot access your SAR copy, go to Student Financial Services in DuBourg Hall, Room 121 and request a copy of
your full SAR report.
If no, please provide a copy of the 2015 tax return to SSS along with this completed application.
PART V: ESSAY
IN APPROXIMATELY 500 WORDS, EXPLAIN,
1. WHY WOULD YOU LIKE TO BE A PARTICIPANT IN THE STUDENT SUPPORT SERVICES PROGRAM?
2. WHAT WILL YOU DO IN THE PROGRAM TO BE AN ACTIVE PARTICIPANT AND A SUCCESSFUL COLLEGE
STUDENT?
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
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________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PART VI:
AUTHORIZATION AND AFFIRMATION
THIS APPLICATION MUST BE SIGNED BEFORE SUBMITTING
1. I hereby authorize the Saint Louis University Student Support Services Program Staff to obtain academic,
financial aid and other information pertinent to my participation in the Student Support Services Program. I also
authorize the Saint Louis University 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 will be shared,
simply the registration status).
2. I understand that a copy of my application will be kept on file at the Student Support Services Program Office and
that the resulting information received from advisors, admission and financial aid officers, instructors, etc. will be
kept confidential in compliance with the Family Education Rights and Privacy Act.
3. 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
Authorizing Signature:_____________________________________
SSS Advisor: __________________________________________________________
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Updated. 01/05/2016