Application of Interest

Personal Information:

*Today's Date: Date of Birth:
*First Name: Middle Initial:
*Last Name:
*Email Address (must be a SEMO email address):
*Student ID number (SO Number):

Address

Local Address
Street City State ZIP
Permanent Address
Street City State ZIP

Phone Contact Information

*Local Phone: Cell Phone: Permanent Phone:

Parents' Education

High School
Graduate
2-Year College
Graduate
4-Year College
Graduate
Mother
Father

Current Academic Standing

Freshman (0-30 hrs)
Sophomore (31-60 hrs)
Junior (61-90 hrs)
Senior (91+ hrs)

If you have participated previously in any of the TRiO Programs, please check which one(s) below:

Upward Bound Talent Search Student Support Services EOC McNair

Ethnicity (Optional)

 Black/African American  Caucasian/White  Hispanic/Latino
 Asian/Pacific Islander  American Indian/Alaskan  More than one race

 
If you are a dependent:   If you are independent:
Parents' adjusted gross income:
$ 		  Your adjusted gross income:
$
Number of persons in household:
   Number of persons in household:

If you are a student with disabilities, are you registered with Disability Support Services?
 YES  NO

I give Student Support Services my permission to review the records necessary to determine my eligibility for the program.
 YES  NO