Student Support Services Application
Last Name: *
First Name: *
Middle Name: *
MU ID: *
Date of Birth: *
Mailing Address: *
Address Line2/Apartment #:
City: *
State: *
Zip: *
Cell Phone Number *
Marshall E-Mail: *
Alternate E-Mail:

Because Student Support Services is a federally funded program, the following personal data questions are asked for statistical purposes.  None of this information will be used for determining your eligibility to participate in the program.
Legal Sex: *
Military Veteran: *
Marital Status *
Number of Dependents: *
Race: *
Please list if more than 1 race:
Are you from Hispanic or Latino Ethnicity?
Preferred Name:
Gender Identity:
Do you currently receive any of the following benefits:
Vocational Rehab
Veteran Benefits
Unemployment
Worker's Compensation
Public Assistance
Social Security/Disability
Are you or will you register with the Office of Disability Services? *
Have you participated in any of the following TRiO Programs:
None
Student Support Services
Upward Bound
EOC (Education Opportunity Center)
Talent Search
If Yes, where was the program located:
Eligibility Data:
Are you a citizen of the United States? *
If No, what country:
Have you been out of school for five or more years? *
If Yes, last year you were in school:
What is the highest level of education your Mother/Guardian completed? *
What is the highest level of education your Father/Guardian completed? *
Did either of your parents/guardians graduate from college with a 4 year Bachelor's Degree? *
Source of income (if known): *

Income Verification:
You may be asked to provide a copy of your income taxes for eligibility purposes.
Who is the Head of Household? *
Number of individuals living in household? *
Current Tax Year? *
I state that the combined family taxable income (line 15 on 1040 or line 6 on 1040EZ) for our household falls into one of these ranges for the Tax Year I have listed above: *
Have you completed the FAFSA for the upcoming academic year? *
If Yes, what financial aid will you receive:
Pell Grant
Student Loan
Promise Scholarship
Work Study
WV Higher Education Grant
Outside Scholarships
Other
Please list all scholarships and other financial aid not listed above:
Education Information:
Current College Standing: *
If a transfer student, what College/University did you transfer from?
College: *
What is your major? *
Are you enrolled Full-time or Part-time? *
High School GPA: *
College GPA:
Did you complete any college courses while in high school? *
Will you be commuting or living on campus? *
If you plan on living on campus, would you be interested in being a part of the SSS Living Learning Community, living on a floor with other SSS students, Resident Advisor and Peer Mentor? *
Do you already have a roommate selected? *
Did someone refer you to Student Support Services? *
If Yes, who referred you to Student Support Services?
T-Shirt Size *
Student Release of Information & Statement of Responsibility:
As a freshman participant in the SSS program, I agree to attend UNI 100 classes, attend at least 1 enrichment activity/workshop each semester, and meet with my SSS Specialist once a week for my first academic year. *
As a sophomore participant in the SSS program, I agree to attend at least 1 enrichment activity/workshop each semester and meet with my SSS Specialist twice a month for that academic year. *
As a junior or senior participant in the SSS program, I agree to meet with my SSS Specialist at least once a month for that academic year. *
I agree to utilize additional University resources, including referrals to counseling, as recommended by SSS staff. *
I agree to notify SSS of any changes in name, address, e-mail address, or phone numbers. *
I agree to notify SSS if I plan to change my major, drop a class, completely withdraw, or transfer from Marshall University. *
I agree to check my Marshall e-mail account on a regular basis for important program notifications and communications. *
I understand as part of my responsibility in the program, I may be required to participate in job shadowing hours to explore a possible career/degree choice. *
I understand spaces are limited and I may not be accepted into the program, even though I meet one or more eligibility requirements. *

By my signature below, I authorize and direct Marshall University to:

  1. Verify my family's income for 2023, 2024 and 2025, using Federal Tax Information (FTI) data from my Free Application for Federal Student Aid (FAFSA), for the purpose of verifying my eligibility to participate in the Student Support Services TRIO program.
  2. Verify my family's non-filing status for 2023, 2024, and 2025 using Federal Tax Information (FTI) data from my Free Application for Federal Student Aid (FAFSA) for the purpose of verifying my eligibility to participate in the Student Support Services TRIO program.
  3. Produce and release an unredacted copy of the 2023, 2024, and 2025 Institutional Student Information Record (ISIR) to my attention for the purpose of verifying my eligibility to participate in the Student Support Services TRIO program

To participate in TRIO programs as a "low-income individual," my family's taxable income cannot exceed 150 percent of the poverty level established by the Census Bureau.  In the absence of an IRS tax transcript, Marshall University will utilize Adjusted Gross Income (AGI) information provided during FAFSA completion.

I agree that verification described in options 1 and 2 may be provided to the SSS Director, specialists and other individuals employed by Marshall University and involved with supervising and directing projects funded under the Federal TRIO programs.

I understand that the above records and information:

  • May include return information disclosed under section 6103(I) of title 26; and
  • May only be used for the specific purpose outlined in this consent form and no other purposes.

It is my intent that this consent form be interpreted to the extent permitted by applicable law, including but no limited to the Internal Revenue Code, the Higher Education Act, and the Family Educational Rights and Privacy Act.

I authorize the TRIO Student Support Services Program (SSS) to gather personal information concerning my academic progress and financial aid status prior to, during, and after my participation in SSS for the reporting period established by the Department of Education.  No one may see this information unless they work with or for the SSS program or are specifically authorized to see the information.

My signature gives the SSS Program permission to access my financial, medical, and academic records at Marshall University or any other educational institution I have attended.  These records include admissions information, high school and college transcripts, financial aid applications, course schedules and grades, disability accommodations, test scores and evaluations deemed necessary for completion of reports required by the Department of Education.  My signature permits SSS staff permission to consult with any Marshall University faculty and staff regarding my academic status.

I understand and give consent to use my picture, taken during various times around the office and SSS activities for the use on brochures, web pages, social media, etc.

I understand the staff is not liable for any lost or stolen personal property while in the SSS office.

I affirm that I am responsible for all material I print in the office and will diligently collect printed items.  I understand that if I fail to do so, the SSS office staff is not responsible for any missing documents or theft of my identity.

I certify I have read and agree to the conditions outlined in the statement above.

By signing below, I am stating that this information is true and accurate to the best of my knowledge.
Applicant Signature *
Please select a signature verification type.
Date: *
Parent/Guardian Signature:
Please select a signature verification type.
Date:

Please select the potential stress factors for you during college.  (The answers indicated in this survey will not affect your overall eligibility for admittance into the program.)
Time Management
Anxiety
Gender Identity
Physical Disability
Work/Job
Money Issues
Relationships
Study Skills
Alcohol/Substanse Use
Depression
Suicidal Thoughts/Ideation
Learning Disability
Wellness Concerns
Cultural Issues
Attention-Deficit Disorder
Adjusting to College Life
Stress Management
Sexual Orientation
Self-Esteem
Lack of Support
Family/Childhood Issues
Assertiveness
Test Taking
Eating Disorder
Other:

What is Your Learning Style & Personality Type?
Please go to http://marciaconner.com/assess/learningstyle-2/ and complete the questionnaire and enter the learning style below. 
Learning Style
Please go to https://www.16personalities.com/ to take the Personality Type Test and submit your response below.
Personality Type Test Results

If you have any questions regarding this form, please contact the Marshall University TRiO SSS office

304-696-3164 • sss@marshall.edu