STUDENT SUPPORT SERVICES/S.O.A.R.

Application Form

STUDENT INFORMATION

Personal Information
Last Name: First Name: Mi:

Student ID No. (if applicable): DOB: Age:

Gender: Male Female Marital Status: Single Married

Street Address:
Apt.No.: City: State: ZIP:

Home Phone: Work Phone:

Cell Phone: Email:

Are you a U.S. Citizen? YES NO (if "yes" please skip next question)

Do you have a permanent resident visa? YES NO
Alien Registration No:

Ethnic Background:
Asian Black or African American Hawaiian/Pacific Islander
Hispanic or Latino Native American/Alaskan Native White

Do you receive Financial Aid? Yes NO

If you receive financial aid, what type are you receiving?
Grant Work Study Loan Scholarship
Scholarship(please specify):

Approximate annual family income:
Number of people in household:

How many hours do you work per week ?
0 1-19hrs/wk 20-35hrs/wk 36 or more hrs/wk

Do you have a high school diploma or GED? Yes No

FAMILY INFORMATION

Does either your mother or father have a four-year college degree? Yes No

NEEDS ASSESSMENT

Do you have a physical or learning disability? This section is optional. You are not required to answer, but a response will help us to determine how we can best help you.
Physical Disability? Yes No Learning Disability? Yes No
If Yes, please explain:

College Grade Level Status: Freshman (0-29hrs) Sophomore (30hrs+)
Other (explain):

What is your current GPA?

When did you first enroll at Richland College?
Number of hours transferred

List any other colleges attended:

How many hours are you enrolled in at Richland College?

Current or planned enrollment at Richland College?
Full-Time (more than 12 hours) Part-Time (less than 12 hours)

Do you plan to graduate from Richland? Yes No
When do you expect to graduate?
Do you have a degree plan on file? Yes No

Services offered by S.O.A.R. Check all that apply to you.
Career Counseling TSI Assistance/Information Study Skills
Academic Advising Scholarship/Financial Aid information Tutoring
Transfer Assistance University Tours Workshops
Knowledge of Richland's Campus Resources

Other (explain):

I certify that all of the above information is correct. I release the following information to Student Support Services: high school transcript, assessment scores, grade reports, financial aid records, and any other information from my records pertaining to my enrollment. I also authorize Student Support Services to release information from my records for the purpose of providing other services that I might need.
Yes No

Form will require a signature during your interview with staff.

» SOAR Home

» TRIO Home
» Ethnic Studies