Student Support Services Application Please complete the form below to apply for the Student Support Services program. If you would prefer, you may print and complete a paper copy of the SSS Application and deliver it to Magale Library 120. HiddenDate Name* First Middle Last Maiden Student ID Number* Home Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Enter Email Confirm Email Do you live on-campus?* Yes No Box Number Residence Hall Room Number Cell Phone NumberCan we text you information? Yes No Date of Birth* MM slash DD slash YYYY Sex Race or Ethnic Group Number of family members living at home last year* Date of entry to SAU (semester and year)* Are you disabled? Yes No Please specify:Are you currently receiving Arkansas Rehabilitation Disability?* Yes No Are you a citizen or permanent resident of the U.S. or its territories or trusts?* Yes No Are you now or have you ever been in foster care?* Yes No Are you now or have you ever been homeless?* Yes No Upon completion of high school or at the time of your 18th birthday, did you live with a parent or guardian who had a four-year degree?* Yes No Do you have a grandparent who has/had a four-year degree?* Yes No Not Sure Do you have a great grandparent who has/had a four-year degree?* Yes No Not Sure Supplemental InstructionSI Leader SI Class What are the three best days and times that you can attend an SI Session during the week?DayTime Click the plus icon to add up to three rows of preferred times. Student Self-Assessment of NeedsI feel that I am not as proficient as I would like to be in the following areas:* Reading Personal counseling Academic counseling Financial counseling Math Tutoring Subjects Writing Study Skills Career Awareness Computer Instruction Other Please specify which subjects in which you could benefit from tutoring: Please elaborate: Are you interested in Student Support Services?* Yes No By submitting this form, I do hereby grant permission to the Student Support Services Program (SSS) to obtain any records from the SAU Financial Aid Office that may pertain to my participation in the SSS.