Date:  _________       Term:  _____
 

SSSC INTAKE FORM

Name:  ________________________________ SSN:  __________________

Address:  ___________________________  City  __________State  _____  Zip  _____

Phone:  _________________________ e-mail:  _____________________________

Date of Birth:  ___________ Gender:  ____M   ____F      Race:  __________________

Major:  ________________   I am enrolled ____ full-time ____part-time.

I will be receiving  ____a certificate    _____a degree.

I will be transferring  ____yes  ____no.  If yes, to _____________________________.
                                                                                      (Name of institution)
My primary language is  ___English   ____Other  (please specify)_______________.

I am                ____Deaf   ____Hard of Hearing        ____ Physically Disabled
(Check all ____Blind   ____Visually Impaired     _____Learning Disabled
that apply) ____Health Impaired  (Specifically ___________________)
  ____Other (Specifically  ____________________________)

My mother’s highest educational level was:  _________________________________. 

My father’s highest educational level was:  __________________________________.

I am  ___receiving a grade of D or below      ___in a Developmental Class
___enrolled in a course below degree level   ___on academic probation 

I have  ___been out of school five or more years
 ___received a High School Equivalency/GED

I am ___receiving a Pell Grant  ___ in a JTP program  ___eligible for TLC
 ___receiving monies from a state program  (Name program______________)
 

I am an ORS client.  My counselor’s name is _________________________________.

Address:________________________City: ________________State:____ Zip: ____

This gives us permission to get a progress report from your instructors.