Student Support Services TRIO

APPLICATION Student Support Services TRIO The University of Texas at San Antonio 0.312 Main Building San Antonio, TX 78249 Office: 210-458-7510 Fax: 210-458-7546 http://p20.utsa.edu/programs/trio_student_support_services/ [email protected] If you need an accommodation to fully participate in this program, please contact Student Support Services at 210-458-7510. Please allow sufficient time to arrange the accommodation.

Last Name: First Name Middle

Name you prefer to be called

Social Security Number Banner ID

Local Street Address

City State Zip Code

Permanent Street Address

City State Zip Code

Cell Phone Number Home Phone Number

Email Address:

Birthdate:

Emergency Contact:

Name: Phone: Relationship:

Which best describes you? Male Female

Do you identify yourself as Hispanic or Latino ethnicity?  Yes  No  Prefer not to answer

What is your race? (Please check all that apply to you.)  White  Black or African-American  American Indian or Alaska Native  Asian  Pacific Island or Native Hawaiian  Prefer not to answer  Other ______

10-01-15 ll First language, if other than English: ______

10-01-15 ll *For all questions on this page: If your did not live with both parents before turning 18 years old, consider the parent you primarily lived with or the parent who provided the most financial support.

1) Are you a citizen or national of the U.S. or do you meet the residency requirements for federal student financial assistance?  Yes No 2) Do either of the parent(s) or guardian(s) you primarily lived with while attending high school have a 4 year bachelor’s degree?  Yes No 3) Do you have a documented physical or learning disability? (Optional)  Yes* No *If yes, is the documentation on file with the MSU Accessibility Resources Office?  Yes No 4) Have you applied for financial aid?  Yes  No If not, do you plan to in the near future? Yes No 5) Were you required to provide your parent(s)/guardian(s) tax information when completing the 2015-16 FAFSA?  Yes – complete section 6A. (include parent signature. Also complete section 6B if you filed taxes) No – complete section 6B.

6) INCOME INFORMATION

A. Parent(s)/Guardian(s): Provide information from parent(s)/Guardian(s) IRS form 1040, 1040A or 1040EZ

1. Number of Exemptions claimed (line 6d of IRS Form 1040 or 1040A) ______If you completed IRS Form 1040EZ and didn’t check either box on line 5, enter 1 if you are single or 2 if you are married. If you checked either the “you” or “spouse” box on line 5, use the 1040EZ worksheet line F to determine the number of exemptions.

2. Taxable Income (line 43 of IRS Form 1040, line 27 of 1040A, or line 6 of 1040EZ): $______

 Did not file 2014 federal income taxes. My family’s total income from the last year was $______

 My family had no taxable income during the last calendar year.

I verify that the eligibility information provided above is true and accurate to the best of my knowledge.

Parent/Guardian Signature Parent Printed Name Date

B. Student: Provide information from your IRS form 1040, 1040A or 1040EZ

1. Number of Exemptions claimed (line 6d of IRS Form 1040 or 1040A) ______If you completed IRS Form 1040EZ and didn’t check either box on line 5, enter 1 if you are single or 2 if you are married. If you checked either the “you” or “spouse” box on line 5, use the 1040EZ worksheet line F to determine the number of exemptions. ______

2. Taxable Income (line 43 of IRS Form 1040, line 27 of 1040A, or line 6 of 1040EZ): $______

 Did not file 2014 federal income taxes. My family’s total income from the last year was $______

10-01-15 ll  My family had no taxable income during the last calendar year.

I verify that the eligibility information provided above is true and accurate to the best of my knowledge.

Student Signature Student Printed Name Date

10-01-15 ll 1. How did you learn about Student Support Services?

2. Which of the following services may be of interest and/or benefit to you? (Please check all that apply).  Class Registration/Schedule Changes  Academic Advising  Career Advising  Major Selection/Degree Plan  Graduate School Advising/Planning  Money Management  Scholarship and Financial Aid Advising  Study Skills/Test-Taking Skills  Campus/Services Info  Peer Mentoring  Tutoring in:

3. What academic challenges are you facing?

Do any of the following apply to you as a student at UTSA? Please check all that apply.  Financial Aid Probation  Academic Warning  Admissions Contract

Have you been involved in any other grant funded or TRiO Programs? Please check all that apply:  Educational Talent Search  Gear Up  Student Support Services (Please list school: ____ )  McNair Scholars Achievement Program  Upward Bound  Upward Bound Math and Science  Veteran’s Upward Bound  OTHER: ______

10-01-15 ll I, ______, hereby grant The University of Texas at San Antonio (“UTSA”) the absolute and irrevocable right and permission, to record my image, likeness and/or voice on a video, audio, photographic, digital, electronic or any other medium (“Recording”) in which I may be included with others, to copyright for same; to use, reuse, alter, edit and publish the same in whole or in part in any and all media including but not limited to use on the world wide web, now or hereafter, and for any purpose whatsoever that UTSA deems appropriate including but not limited to, exhibition, education, illustration, promotion, art, advertising and trade, and if appropriate, to use my name and pertinent education and/or biographical facts as UTSA chooses. I hereby release and discharge UTSA, its governing board, officers, representatives, employees and agents from any and all claims and demands for compensation arising out of or in connection with the use of the Recording. I hereby release and discharge UTSA, its governing board, officers, representatives, employees and agents from any and all claims and demands arising out of or in connection with the use of the Recording, including without limitation any and all claims for libel or invasion of privacy. I am of full age and have the right to contract in my own name. I have read the foregoing and fully understand its contents. This release shall be binding on me and my heirs, legal representatives and assigns.  Check here if not 18 years of age or older (we will supply you with an alternative form for parent signature)

Signature: Date:

I certify that the information I have provided on this application is, to the best of my knowledge, true and correct. Furthermore, I understand that by applying for this program, I authorize the Student Support Services Program to obtain records or data pertinent to my participation from other sources (including, but not limited to, Financial Aid, Student Disability Office, and Office of the Registrar), and to release information as required by law or the terms of the Student Support Services Grant, to the grant-funding agency of the federal government**. I further authorize Student Support Services Staff to discuss issues related to my academic progress with other university faculty and staff for the purpose of coordinating academic and personal support services.

Signature Date ** The University of Texas at San Antonio Student Support Services (SSS) is asking you to provide information which includes private information under state and federal law. SSS is asking for this private information so that we can process your application for your admission to our program. This information will be used to evaluate your application for admission to determine whether you are a suitable candidate for admission into our program. You are not legally required to provide the information SSS is requesting, and you may refuse to provide some or all of the information requested. However, SSS may not be able to consider your application if you do not provide sufficient information. With some exceptions, unless you consent to further release of private information, access to this information will be limited to the individuals involved in our admission process (including the Financial Aid, Student Disability Office, and Office of the Registrar) and the advisors and clerical personnel of the program. However, federal and state laws do authorize release of private information without your consent to: school officials who have legitimate educational interests in the information; the U.S. Dept. of Education for the purposes of program compliance, audit or evaluation; a court, grand jury, or state or federal agency, if the information is sought with a subpoena; appropriate persons in connection with an emergency, if necessary to protect your health or safety or the health or safety of others; if required by a court order, or permitted by other state or federal law. PRIVACY ACT In accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Education is authorized to collect information to implement the Student Support Services Program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, Sec. 402D). In accordance with this authority, the Department receives and maintains personal information on participants in the Student Support Services program. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. Providing the information on this form, including a social security number (SSN) is voluntary; failure to disclose a SSN will not result in the denial of any right, benefit or privilege to which the participant is entitled. The information that is collected on this form will be retained in the program files and may be released to the National Student Clearinghouse or other UTSA department officials in the performance of their official duties.

Student Support Services is a federally funded program by the U.S. Department of Education in cooperation with The University of Texas at San Antonio. $220,000 in federal funds (92% of program budget) has been allocated for the current grant year. The University of Texas at San Antonio is an equal opportunity educator and employer.

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