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Program Eligibility Application

Dear Prospective Participant,

You will be submitting the important information needed by Student Support Services by completing this form. However, you need to turn in or fax a copy of the signed release form (link on left menu) to SSS at 509-963-1620 declaring the information provided is complete and true.

Thank you in advance for your participation.

Email:
Last Name:
Middle Initial
First Name:
What is your gender? Male     Female
Campus Address (Current):
CITY STATE ZIP

Permanent Address:
CITY STATE ZIP
Phone Number: - -
Date of Birth: / /
Last 4 Digits of Social Security Number:
Ethnicity (optional):
Are you a U.S. Citizen? Yes     No
OR
Are you a permanent resident? Yes     No    If yes, A#:
Are you currently enrolled or accepted at CWU? Yes     No
Do you have a documented disability? Yes     No
If yes, have you submitted documentation of your
disability with Disability Support Services?		 Yes     No
Do you have a Baccalaureate degree? Yes     No      If yes, What is it?
Mother's Education Level: Basic Education:   College:
Mother's Highest Degree Earned, if any:
Father's Education Level: Basic Education:   College:
Father's Highest Degree Earned, if any:
Did you apply for Financial Aid? Yes     No
Have you recieved your financial aid letter? Yes     No
(If you did not apply for financial aid and wish to be considered for the Student Support Services program under the low-income eligibility
criteria, please attach a copy of your [or your parents', if dependent] 2000 Federal tax return.)
Choose the Areas in which you would like assistance: (to select multiple choices hold the "CRTL" key down, on MAC use the Apple key)

 Other:

Have you participated in a TRIO program at another institution? (Student Support Services, Upward Bound, Upward Bound Math Science, Educational Talent Search, Veterans Upward Bound, or Educational Opportunity Center)? Yes     No    If yes, which program?:
How did you hear about Student Support Services?
Please tell us briefly why you want to participate in the SSS program?
A copy of the signature page is required in order for the application to be completely processed. Please fax a copy of the signature page to SSS at 509-963-1620.
         

Contact Information
Student Support Services
400 East University Way
Ellensburg, WA 98926-7430
Phone:(509) 963-1620
e-mail: @cwu.edu
Contact Information
Student Support Services
400 East University Way
Ellensburg, WA 98926-7430
Phone:(509) 963-2026
Fax: (509) 963-1620
e-mail: garcial@cwu.edu
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