Student Support Services

Application

First Name:
Middle Name:
Last Name:
Date of Birth:	mm/dd/yyyy
JBU Email:
Live on Campus? Yes No
JBU Box Number:
Residence Hall:
Permanent Address
Street:
City:
State:
Zip Code:
Home Phone Number:
Cell Phone Number:
Name of Wireless Provider:
Would you like to receive text messages? YesNo
Personal Information
You are a(n):
Ethnicity:
Referred By:
Mother's Education:
Father's Education:
Type of Financial Aid Received:	Veteran's Benefits AR Rehabilitation College work study Workforce One Stop Loans	Pell Grant SEOG I did not apply I am not eligible Other
Number of members in immediate family:
Do you have a disability? YesNo
If yes, is it documented with JBU Office of Disability Services? YesNo
Education
Major:
Minor:
Classification:
JBU Entrance Date:
First time in college? YesNo
Are you a transfer student? YesNo
High school:
High school GPA:

Please indicate the following areas with which you struggle and/or need assistance.
Reading Comprehension	Reading Speed
Math Concepts	Math Anxiety
Grammar and Mechanics	Organizing Your Writing
Time Management	Prioritizing Tasks
Organizational Skills	Listening Skills
Memory Skills	Goal Setting
Choosing a Major	Conflict Resolution
Finding Your Learning Style	Stress Management
Choosing a Career	Preparing for GED
Note-taking Skills	Research Skills
Test Anxiety	Test Preparation
Test-taking Skills	Basic Computer Skills
Using my Syllabi	Deciding about Graduate School
Writing a Resume	Job Interviewing Skills
Job Search Skills	Personal/Family Issues
Financial Issues

Particular class(es) I struggle with:
Other areas I struggle with:

I wish to participate in the Student Support Services Program in order to achieve my educational goals. I agree to participate in all recommended services and will keep all scheduled appointments to help achieve these goals. I give SSS permission to secure any of my necessary academic and financial records to verify my eligibility for program participation and to determine an effective academic plan. Information deemed appropriate may be obtained through correspondence with the Financial Aid Office, Office of Disabilities, JTPA, Rehabilitation Services or other educational information. I give the SSS advisor consent to have verbal and written contact with any of my professors regarding my academic progress in their class. The pertinent information reviewed will include class attendance, preparedness and academic progress. I agree that the information I provided on this application is true to the best of my knowledge.

NOTE: The information requested in this form is used strictly to determine program eligibility as well as to provide program demographics to the Department of Education. ALL information will be kept in confidence by program staff. The JBU Student Support Services Program does not discriminate on the basis of ethnicity, gender, age, national origin or disability.