Centralia College
Student Support Services
APPLICATION
000-00-0000
000-000-000
Social Security #
Centralia College ID #
00/00/00
(360)-000-0000
Mailing Address
Date of Birth
Phone #
City, State, Zip
E-mail Address
Name (Last, First, Middle Initial)
Gender
Male (1)
Female (2)
AEthnicity
cCitizenshipp
1. American Indian/Alaskan Native
2. Asian
3. Black/African-American
4.
5.
6.
7.
Hispanic/Latino
Caucasian/White
Hawaiian/Other Pacific Islander
Other
Has either of your parents received a 4-year college degree?
Yes
U.S. Citizen
U.S. National
Meet the
residency requirements for Federal
student financial aid
No
Do you have a diagnosed physical or mental impairment that substantially limits your ability to participate in the
educational experiences and opportunities offered by Centralia College?
Yes
No
Prior Education
High school diploma
High school(s) attended
Year
GED
College(s) attended & year
Year
Level of Education Planned at CC
AA (Arts)
AAST
AS
IDP (Individualized Degree Program)
(Science)
(Applied Science-Transfer)
ATA (Technical Arts)
AGS
Certificate
Other
Are you currently registered for 6 or more college-level (100 level or above) credits at CC?
Do you plan to transfer to a 4-year college/university?
Yes
No
Program Eligible
Ineligible
Academic Need Code
Intended field of study
Updated 7/24/2016 - de
No
For Office Use Only
Name of proposed 4-year college/university
Career goal/occupation
Yes
(General Studies)
Staff Assigned:___________
-OVER-
1.
2.
3.
4.
5.
LI, FG
LI Only
FG Only
Disability
Disability & LI
1. Did you or your parents/legal guardian file income taxes for year 2006?
Yes
No
2. If yes, what was your TAXABLE income? $
3. Number of EXEMPTIONS claimed?
4. Have you applied for financial aid at CC?
Yes
No
5. Are you receiving financial aid at CC?
Yes
No
6. Are you receiving special training money?
Yes
No
Type:
DVR
VA Assistance
WorkFirst
If yes, date applied:
Month/Year
Worker Retraining
Other
Check any of the following services that may interest and/or benefit you.
Academic Assistance
Academic assistance
Career planning
Scholarship planning
Transfer Planning
College information
College application assistance
College visits
Academic Support
Professional tutoring
Textbook loan
Equipment loan
Personal Assistance
Study skills
Overcoming test anxiety
Stress management
Graphing/scientific calculator
Writing an effective paper
Test taking strategies
Financial aid/FAFSA
Scholarship workshop
Personal budgeting
Cultural and Enrichment Activities
Field trips, lectures, symposiums
Check obstacle(s) that might prevent you from achieving your academic goals.
Poor study skills
Childcare issues
Taking the wrong classes
Always feeling tired
Afraid to speak up in class
Too shy
Test anxiety
Bad grades
Take things too seriously
Problems at home
Trouble sleeping
Transportation
Feeling depressed or sad
Lack of family/friend support
Family/personal medical problems
Separation or divorce
Time management
Constant worrying
Financial Issues
Unsure of goals
Other
How did you learn about Student Support Services?
Are you a previous Student Support Services (SSS) participant?
Yes
No
Are you a previous Educational Talent Search (ETS) participant?
Yes
No
Year(s)
Release of Information
I certify that the information I have provided is, to the best of my knowledge, complete and accurate. I authorize
SSS program staff to obtain records or data from other campus offices and/or public agencies pertinent to my
education and participation. I understand that all information provided will be confidential as specified in the rules
and regulations of Centralia College.
Yes
No
I give SSS permission to use interviews, photographs, or videotapes of myself to be used in radio, TV, printed news
media, or in program promotional materials and documents.
Yes
No
Student Signature:
Date:
Submit Application