SSS Application

MHU Student Support Services Program Application
General Information
Name

First NameMiddle NameLast Name
Student ID
Residence Hall
Email
example@mhu.edu
Phone Number

Area CodePhone Number
Gender

MaleFemale
Home Information:
Parent/Guardian Name:

First NameLast Name
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Campus Information:
Mail box:
Faculty Advisor:
Major:
Race

WhiteBlack or African AmericanAsianNative Hawaiian or Pacific IslanderAmerican Indian or Alaskan NativeMore than one race
Ethnicity

Hispanic or LatinoNon Hispanic or Latino
Resident Status

US CitizenTerritory ResidentPermanent VisaResident Alien
Eligibility Information
Are you

SingleMarried
With whom have you lived during the past year (who can claim you on their income tax records?)

FatherMotherFather AND MotherGrandparent(s)GuardianSpouseI am self-supporting
Has your mother GRADUATED from a 4-year-college?

YesNo
Has your father GRADUATED from a 4-year-college?

YesNo
Do you have a disability that you wish to disclose?

YesNo
If so, is it DOCUMENTED at MHU?

YesNo
Educational Background
High School
Year Graduated
Transfer Student
(College/University)
Why are you in college?
What are your career goals?
How did you hear about Student Support Services? (Student/coach/instructor/brochure/etc)
What services or items do you need that you think SSS may be able to provide?
I agree that the Student Support Services office may access any of my records stored at the University for determining my program eligibility and/or for advertising. I further agree that the information provided is true and accurate to the best of my knowledge. I hereby give my permission to the Student Support Services staff to release pertinent information in my file to faculty members or professional staff if the Student Support Services office determines that doing so is in my best personal and or/academic interest.
Signature

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Date

MonthDayYear
Date
MHU Student Support Services
Needs Assessment
What services do you need from Student Support Services?

Academic Advising/Degree PlanningPersonal CounselingCareer CounselingFinancial Aid AdvisingGraduate School Information/AdvisingTutoring
If you selected tutoring, please list courses:
SSS offers workshops each semester. Please rank the following order 1-9 as they interest you. 1=most interested/would attend; 9=least interested/would not attend
Are any of the following currently concerns that would affect your academic goals? Check all that apply

Too shyNo close friends at MHUUndecided MajorPoor writing skillsLack of child careAlways worryingRecurring health concernsNo support from familyFeeling unprepared for collegeEasily distractedPoor study habitsProcrastinationProblems at homeRoommate problemsFinancial concernsTrouble understanding what I readLack of a place to studyFamily medical concernsPoor math skillsFeeling out of place at schoolRelationship problemsLack of career goalsAfraid to speak up in classFeeling depressed or sad
Are you currently having trouble with any courses? If yes, please list and explain.
Do you have any difficulty approaching professors with problems or concerns? If yes, please explain.
List ALL activities in which you participate other than school/classes (job, athletics)
Do you have all of your books and supplies for the semester? If no, please explain.
Student Signature

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Date

MonthDayYear
Date
Should be Empty:

MHU Student Support Services Program Application

General Information

Home Information:

Campus Information:

Eligibility Information

Educational Background

MHU Student Support ServicesNeeds Assessment

MHU Student Support Services
Needs Assessment