Student Success Hub Intake Form

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Welcome!

The Student Success Hub provides academic and non-academic support to ECTC students. Please complete the following form to receive personalized services from the Hub. If you have questions about this form or Hub services, please call 270-706-8432.

14Questions

1
Name* This field is required.Please enter your full name - first and last.
First Name
Last Name
2
Student ID Number* This field is required.Please enter your KCTCS student ID number. You can find this number on your Student Self-Service.
3
Student Email* This field is required.This is your KCTCS email - ex: jsmith0001@kctcs.edu
example@example.com
4
Phone NumberPlease provide an active phone number.
Please enter a valid phone number.
5
RaceThis is an optional question.
Please Select
Please Select
Black/African American
Native American/Alaska Native
Pacific Islander/Native Hawaiian
Asian
Hispanic/LatinX
Caucasian
Two or more
6
Gender IdentityThis is an optional question.
Please Select
Please Select
Male
Female
Non-Binary
Other
7
Are you a first-generation college student?* This field is required.Neither parent has completed a bachelor's degree.
YESNO
8
Are you Pell Grant eligible?You currently receive the Pell Grant. You can find a list of financial aid awards on your Student Self-Service.
YESNO
9
As a student, I need to:* This field is required.Please select all that apply.
improve my writing skills
Improve my reading skills
Improve my math skills
Improve my note-taking skills
Improve my time management
Improve my GPA
Manage my test anxiety
Enhance my career skills
Understand my program plan
Discuss my transfer options
N/A
10
Are you currently facing any of the following non-academic difficulties?* This field is required.Please select all that apply.
Food insecurity
Clothing insecurity
Unreliable childcare
Unreliable transportation
Unreliable housing
Lack of hygiene essentials
English as a second language
Financial hardship
Loneliness
Access to counseling services
N/A
11
Would you like to know more about Hub enrichment opportunities?Please select all that apply.
Advancing multiculturalism
in-state travel
Study abroad
Workshops
Seminars
Leadership
Mentoring
Peer tutoring
Networking
Community service
Clubs
Work-study
12
Do you have any specific concerns you would like Hub staff to address?Type your response below.
Huge
Large
Normal
Small
Ok
Ok
13
Would you like to learn more about a specific Hub program?Select all that apply.
Multi-Cultural Center
Student Support Services (TRIO)
Math tutoring
Writing tutoring
Family Scholar House
Success Coaching
14
Have you received any emails or calls from the Student Success Hub this semester?* This field is required.
YESNO
Should be Empty:

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