CALIFORNIA STATE UNIVERSITY DOM I NGUEZ HILLS Application for Program Services #TRIOWORKS What is Student Support Services? Student Support Services is a federally funded program designed to provide academic assistance and enhance educational opportunities for students. Federal guidelines require students to be from low-income families, firstgeneration college students, and/or have a documented disability. Participants must also have an academic need for our program. Our program is designed to support the academic needs of 160 eligible CSU, Dominguez Hills students. Participants are offered an array of services to ensure a smooth transition to CSUDH as well as ongoing support towards the successful completion of their postsecondary education. This program is offered free of charge to participants. Eligibility is based on federally funded criteria: Students who meet low-income qualifications Students whose parents have not earned a bachelor s degree Individuals who have a documented disability SSS participants must be: U.S. citizens or permanent residents Admitted and enrolled at CSU, Dominguez Hills Pursuing a first bachelor s degree Needing academic support Committed to utilizing academic support to earn a bachelor s degree SSS Application Packet Checklist: SSS Application Unofficial Transcripts Copy of your ID (state or school) Income Tax form 1040 (form must be signed) If you did not file your income tax: submit your FAFSA Student Aid Report (SAR) or a statement stating that you did not file will be accepted. SSS Office Location Student Support Services 1000 E. Victoria St. East Academic Complex (EAC) 300 Carson, CA 90747 Phone: 310-243-2143 Fax: 310-217-6987 Email: SSS@csudh.edu Website: http://www4.csudh.edu/sss/ How can SSS help you? Academic advising Academic and personal support Computer lab and printing access Tutoring services Graduate school assistance Financial literacy education Priority Registration Cultural field trips Student leadership conference opportunities 1
Please read and complete all sections on the application. Incomplete applications will delay processing. Upon completion, please submit the application in person, via mail, email or fax. SSS Office Use ONLY Eligibility: U.S. Citizen Low Income First Generation Both Disabled Foster Youth Cohort: Class Standing: Date Received Academic Need:_# Yes No Accepted: Yes No Financial Aid: Verified Taxable income: $ Family size: Director s Signature: Acceptance Notification Date: STUDENT DEMOGRAPHIC INFORMATION First Name: Middle Initial: Last Name: Social Security Number: - - required by the U.S. Dept. of Ed. Student ID Number: Date of Birth: Gender: Female Male Address: City: State: Zip: Home Telephone: Cell Phone: CSUDH Email: Alternate Email: What is the best way to contact you? (circle one) cell phone text message home phone email Ethnicity Hispanic/Latino Race Native American or Alaska Native Asian American Black/African American Caucasian/White Native Hawaiian/Pacific Islander Other: Marital Status: (circle one) Single Married Divorced Separated Widowed 2
EDUCATIONAL INFORMATION Freshman Only 1. What high school did you attend? (name, city and year you graduated) 2. Circle all tests completed: SAT Verbal SAT Math ACT English/Math/Reading/Science/Composite 3. High school cumulative GPA: Transfer Student Only Are you a transfer student from another college/university? (circle one) YES NO If yes, name of previous colleges/ universities you have attended: College Standing (circle one) Freshman (0-29 units) Sophomore (30-59 units) Junior (60-89 units) Senior (90+ units) College Major: Minor: Are you currently enrolled/plan to: (circle one) Full-time (12+ units) Part-time When do you expect to graduate? Are you a former TRIO participant? Yes No If yes, what TRIO program? Are you interested in obtaining a Master s degree in the future? Yes No Current College GPA (cumulative GPA) ELIGIBILITY INFORMATION Did your Father complete a Bachelor s Degree? Yes No N/A Did your Mother complete a Bachelor s Degree? Yes No N/A Are you a Veteran of the Armed Forces? Yes No Are you or have you been considered a ward of the state or foster youth? Yes No Are you a U.S. Citizen or Permanent Resident? (circle one) Yes No Do you have a disability? Yes No If you circled yes, please indicate the nature of your disability: Do you receive supplemental income due to your disability? Yes No 3
Have you registered with the CSUDH Student disability Resource Center? Yes No FINANCIAL INFORMATION IF YOU ARE AT LEAST 24 YEARS OLD OR IF YOU ARE CONSIDERED TO BE AN "INDEPENDENT STUDENT ON THE FAFSA, YOU MUST ANSWER THE FOLLOWING QUESTIONS ABOUT YOURSELF. IF YOU ARE LESS THAN 24 YEARS OLD AND YOU ARE CONSIDERED TO BE A DEPENDENT STUDENT ON THE FAFSA YOUR PARENT / GUARDIAN MUST ANSWER THE FOLLOWING QUESTIONS AND SIGN THIS DOCUMENT TO VERIFY. What is the number of persons, including yourself in your household (family size claimed on taxes) Annual Household Taxable Income: $ If you or your family did not file a federal income tax last year, please state your family s total income from last year: My family had no taxable income last year (please attached a written or typed statement) How do you plan to pay for college? (circle all that apply) Grants Scholarships Loans Personal Income Have you completed the FAFSA for this academic year? (circle one) YES NO Are you receiving financial aid for this upcoming academic year? (circle one) YES NO Have you applied for any scholarships for this upcoming academic year? (circle one) YES NO NEEDS ASSESSMENT What academic or other barriers do you feel will be a challenge to completing your degree at CSU Dominguez Hills? 4
Briefly discuss your academic and career goals and please also share how you stay motivated to achieve your goals. What services are you seeking from TRIO Student Support Services? Check all that apply Academic advising Academic support Personal support Guidance Study skills Career planning Internship assistance Graduate school information Time management skills Computer lab / free printing Study Space Financial literacy education Choosing a major Personal counseling Tutoring services FAFSA assistance Resume assistance Computer skills Stress management Scholarship application Priority registration Do you work or plan to work? If yes, how many hours per week? Do you have more than one job? Where do you work? Do you plan to live on or off campus? Please list other concerns or needs: 5
INFORMATION & AUDIO/VISUAL RELEASE Submitting this application enables California State University, Dominguez Hills (CSUDH) TRIO Student Support Services to obtain necessary academic and personal information and records; including grade reports and transcripts, admission, enrollment, financial aid eligibility and awards, U.S. residency status demographic and contact information for the purpose of determining eligibility, developing education plans, recording and collecting program statistics. I further authorize the CSUDH TRIO Student Support Services to use information and photographs related to my program participation in newsletters, CSUDH, TRIO, WESTOP webpages & social media releases and other program-related publications. This information may be shared with the U.S. Department of Education, California State University, Dominguez Hills and TRIO personnel in accordance with federal regulations and CSUDH university policies. I/We certify that all of the information contained within this application is complete and correct to the best of my knowledge. Student signature: Date: Parent/Guardian s signature: Date: (Parent /Guardian signature is required if student is under the age of 24 and is considered a DEPENDANT student) Statement of Confidentiality: The information contained in this application is for the purpose of determining the applicant s eligibility for the Student Support Services Program. All information received is confidential. Revised June 2017 TRIO Student Support Services at CSUDH is 100% federally funded. 6