SSS Application

MHU Student Support Services Program Application
General Information
Name

First Name Middle Name Last Name
Student ID
Residence Hall
Email
example@mhu.edu
Phone Number

Area Code Phone Number
Gender

Male Female
Home Information:
Parent/Guardian Name:

First Name Last Name
Home Address

Street Address

Street Address Line 2

City State / Province

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

White Black or African American Asian Native Hawaiian or Pacific Islander American Indian or Alaskan Native More than one race
Ethnicity

Hispanic or Latino Non Hispanic or Latino
Resident Status

US Citizen Territory Resident Permanent Visa Resident Alien
Eligibility Information
Are you

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

Father Mother Father AND Mother Grandparent(s) Guardian Spouse I am self-supporting
Has your mother GRADUATED from a 4-year-college?

Yes No
Has your father GRADUATED from a 4-year-college?

Yes No
Do you have a disability that you wish to disclose?

Yes No
If so, is it DOCUMENTED at MHU?

Yes No
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

Month Day Year
Date
MHU Student Support Services
Needs Assessment
What services do you need from Student Support Services?

Academic Advising/Degree Planning Personal Counseling Career Counseling Financial Aid Advising Graduate School Information/Advising Tutoring
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 shy No close friends at MHU Undecided Major Poor writing skills Lack of child care Always worrying Recurring health concerns No support from family Feeling unprepared for college Easily distracted Poor study habits Procrastination Problems at home Roommate problems Financial concerns Trouble understanding what I read Lack of a place to study Family medical concerns Poor math skills Feeling out of place at school Relationship problems Lack of career goals Afraid to speak up in class Feeling 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

Month Day Year
Date
Should be Empty:

MHU Student Support Services Program Application

General Information

Home Information:

Campus Information:

Eligibility Information

Educational Background

MHU Student Support Services Needs Assessment

MHU Student Support Services
Needs Assessment