Program Application Form

Program Application Form

This program is funded $327,836 annually by the U.S. Department of Education.
First Name*
Middle Name
Last Name*
M# (Student ID)
Permanent Mailing Address (Parent's)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Local Address (While attending MSU)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Cell Phone*
Please enter a valid phone number.
Murray State Email Address*
@murraystate.edu
Preferred Method of Communication*
Date of Birth*

MonthDayYear
Date of first enrollment at MSU*

MonthDayYear
First semester attending MSU*
i.e. Summer 2024, Fall 2024, Spring 2025
Sex (assigned at birth)*

FemaleMale
Preferred Pronouns*

they/them/theirsshe/her/hershe/him/his
Race (check all that appy)*

American Indian/Alaskan NativeAsianBlack/African AmericanNative Hawaiian/Other Pacific IslanderWhite
Do you identify as Hispanic/Latino?*

YesNo
Have you participated in any of the following TRIO programs? (check all that apply)*

Upward Bound (UB)Upward Bound Math & Science (UBMS)Veterans Upward Bound (VUB)Educational Talent Search (TS- ETS)Student Support Services (SSS)McNair Scholar's Program (McNair)Educational Opportunity Center (EOC)None
Do you have an application for Federal Financial Aid (FAFSA) on file with the Financial Aid Office?*

YesNo
Are you a veteran of the U.S. Armed Forces?*

YesNo
If yes, which branch?
Name of person who referred you to the program. (if applicable)
Eligibility Criteria: Funding for the SSS program is provided by the U.S. Department of Education and requires specific documentation for enrollment into the TRIO Student Support Services Program.
Citizenship Status - Are you a U.S. citizen or permanent resident? (CFR646.30: a citizen or national of the United States or meets the residency requirements for Federal student financial assistance.)*

YesNo
First-Generation status (parent(s) or guardian(s) educational level)*

Mother has a 4-year degreeMother does not have a 4-year degreeFather has a 4-year degreeFather does not have a 4-year degreeBoth parents do not have a 4-year degreeBoth parents have a 4-year degree
Residency Status-who you live with (check all that applies)*

MotherFatherGuardian(s)Foster ParentOther
Using the following criteria, are you considered homeless? 1.) Lack a fixed, regular, and adequate nighttime residence. (i.e. couch surfing) 2.) Primary nighttime residence is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for humans. 3.) Share the housing of other persons due to loss of housing, economic hardship, or similar reason. 4.) Currently living in a hotel, motel, trailer park, or campground due to lack of alternative, adequate accommodations. 5.) Currently living in an emergency or transitional shelter. 6.) Currently living in car, park, public space, abandoned building, substandard housing, bus or train station, or similar setting.*

YesNo
Disability Status (optional)
Do you have a documented Disability

YesNo
Are you able to provide documentation of disability to the SSS office?

YesNo
Are you registered with the Student Disability Services Office at Murray State?

YesNo
Do you have documentation of your disability on file with the Student Disability Office at Murray State?

YesNo
Academic Goals: Please answer the following:
Have you taken, or will take any developmental/remedial/corequisite courses at MSU?*

YesNo
What is your Major/Field of Study (type undeclared if you have not decided)?*
What is your Minor?*
Earnings Certification
Household size and income: What is your federal tax filing status according to your most recently filed federal taxes?*

Independent - You are independent if ANY of the following conditions apply to you: 1.) You were 24 years of age on or before December 31st of last year. 2.) You have a dependent child or parent. 3.) You are a member or veteran of the U.S. Armed Forces. 4.) At any time since you turned 13, both of your parents were deceased, you were in foster care, or you were a dependent or ward of the court.Dependent - You are a Dependent if ALL of the following conditions apply to you: 1.) You were under the age of 24 on December 31st of last year. 2.) You do not have a dependent child. 3.) You are not a member or veteran of the U.S. Armed Forces 4.) At any time since you turned 13, one or both of your parents were living, you were not in foster care, nor were you a dependent or ward of the court.
Household Size: how many people are in your household if Independent, include yourself, your spouse, and any other dependents. If Dependent, include yourself, your parents or guardians, and all other persons.*
Federal Taxable Income: You do not need to reveal your family’s exact income to determine if you are income eligible for the Student Support Services project.

If your family’s taxable income is below the figure which corresponds to your family size, select "Yes" for the following "Does your income qualify?" question.

To determine your taxable income, refer to line 15 on your 2022 Federal tax return.

1........$22,590

2........$30,660

3........$38,730

4........$46,800

5........$54,870

6........$62,940

7........$71,010

8........$79,080
Does your income qualify you?*
Did your family file taxes in 2023?*

YesNo
Please certify that all the information provided in the above sections are true, correct, and complete. (If the applicant is under the age of 24 on December 31st of last year, a parent or guardian must sign below).
Certifying Signature Required*

Clear
1st Professional reference First Name* Last Name*
Reference's email address Email* .
2nd Professional reference First Name* Last Name*
Reference's email address Email* .
Release of Information/Student Publicity Release

I certify that the information I have provided on this application is, to the best of my knowledge, complete and accurate. Futhermore, I understand that by applying for the Student Support Services program. I authorize SSS staff to obtain any personal, financial, academic, or medical information relevant to my participation in SSS. I also authorize SSS to release information including, but not limited to, my class schedule, academic/educational information, and financial aid information to the U.S. Department of Education and other appropriate federal and/or state agencies. The SSS staff also has my permission to communicate verbally or otherwise with staff, faclty, and/or off-campus professionals on my behalf.
Student Signature*

Clear
I agree that if I am accepted into the Student Support Services program, the staff may use my name or picture in publications, bulletin boards/posters, social media outlets, and/or campus publications for the purpose of highlighting accomplishments and participation in campus and SSS activities.
Student Signature

Clear
Participation Requirements

To be a participant in the Student Support Services Program at Murray State University, I agree to do the following:

1.) Complete a needs assessment with a SSS staff member each Fall and Spring semester.

2.) Create an academic plan through the Individualized Academic Map Process (I-MAP).

3.) Receive services based on my needs assessment and Plan of Action provided by Student Support Services.

Required Services - (based on need) include: Tutoring, Post-Secondary Course Selection Assistance, Federal Financial Aid Counseling, Financial & Economic Literacy, and Graduate & Professional School Counseling.

Permissible Services - (based on need) include: Career Counseling, Study-skills Enhancement, Cultural & Academic Programs, and Personal Developement.

4.) Each Semester, I will Update my plan by identifying needed services.

5.) Meet with a SSS staff member a minimum of one (1) time each semester for academic counseling or services.
Student Signature*

Clear
By signing this form, I agree that all responses contained in this application are true and accurate.
Student Signature*

Clear
SSS Director Signature (For office use only)
________________________________________________________
Should be Empty:

Program Application Form

Release of Information/Student Publicity Release