Thank you for your interest in our Student Support Services program!  Please complete this application as thoroughly as possible.  You cannot save and restart this application. If you have any questions, please email

Biographical Information:
First Name: *
Middle Initial:
Last Name: *
Date of Birth: *
School ID
Address: *
Address 2:
City: *
State: *
Zip Code: *
Home Phone
Cell Phone Number:
Email Address:
Preferred Name
Are you a United States Citizen or Permanent Resident?
Non-citizen's Visa Number (if applicable)
Race Classification (for statistical purposes only) *
Are you Hispanic or Latino? *
Do you have a documented disability?
Have you submitted documentation of your disability to the Accessibility & Resource Services at Shawnee Community College?

Educational Information:
High School Graduation Year (if applicable)
GED Completion Year (if applicable)
Parents Educational Level:
Which do you plan to complete at Shawnee Community College
What is your intended major?
Have you already completed a 2-year or 4-year degree?
If so, which degree and from which school?

Sign and Submit:


The information on this form is confidential and will help determine eligibility for SSS.  I declare that the information given here is true and correct to the best of my knowledge.  I authorize Student Support Services access to my student records, including academic records and financial awards and any other information pertaining to my enrollment in SSS.  Additionally, if I transfer to another institution, I authorize SSS to contact said institution and/or the National Student Clearinghouse for follow-up information.

Applicant Signature *
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Signature: (Type in your full name)
I agree to the terms included.


Office Use Only:

Advisor Signature:  _______________________________________________  Date:  __________

Director Signature:  _______________________________________________ Date: ___________

FG ______  LI _____ D _____ FG/LI _____ D/LI _____

Acceptance Date:  _____________   Semester _______

1st year never attended ____ 1st year attended before (below 30 hours) ____ 2nd year ____

Current Cumulative GPA _________  Dual Credit/Escrow?  Y  N