Student Success Intake Form

PERSONAL INFORMATION
Full Name (first and last name): *
Previous Name When You Were Last Enrolled
Home Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone Number:

Area Code Phone Number
Home E-mail Address:
Contact Information Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Contact Information Phone Number:

Area Code Phone Number
Contact Information E-mail Address:
Date of birth: *

Month Day Year
Gender

Female Male Gender Neutral
Race

American Indian or Alaskan Native Asian Black or African American Native Hawaiian or Pacific Islander White
Ethnicity

Hispanic Latino Spanish Origin
Are you a first-generation college student (you are the first in your family to attend college)?

Yes No Don't Know
EMPLOYMENT
What is your current employment status?

Full Time Part Time Two or More Jobs Unemployed, but actively searching (filling out applications and resumes) Not Able to Work Retired
Does your employer offer tuition reimbursement benefits?

Full Partial Does not offer reimbursement Don't know
ADDITIONAL INFORMATION
Have you ever received Financial Aid assistance (grants, loans, work study)?

Yes No
Are all your student loans current and in good standing?

Yes No I don't know
Did you enroll in another institution after RIC?

Yes No
Where were you enrolled?
Do you have college credentials from another country outside the United States?

Yes No
What is your intended major?
Did you fill out your FASFA for this year?

Yes No
Would you like to be connected to Learning For Life upon re-enrollment?

Yes No
How did you hear about Finish Strong?
Should be Empty:

PERSONAL INFORMATION

EMPLOYMENT

ADDITIONAL INFORMATION