SSS Application Form

* = required field

PART I: APPLICANT INFORMATION
Last Name*
First Name*
Middle Initial
Nickname
Luther ID*
Soc. Security #
Date of Birth*
Home Address (Street or P.O. Box)*
Home City, State, Zip*
Home Phone
Cell Phone Number
Cell Phone Carrier or Brand
Email (other than Luther email)
Emergency Contact Name*
Relationship of Contact to You*
Emergency Contact Phone Number*
Gender*
Citizenship*
Race/Ethnicity: (check all that apply)*
Do you have a documented disability (physical disability, learning disability, etc.)?*
If yes, have you been in contact with Luther College Disability Services?
If you were referred to SSS, please indicate the individual’s name and title:
PART II. ACADEMIC INFORMATION
Student Status*
Expected Year of College Graduation
Have you participated in another TRiO Program or similar support program?*
If yes, please specify
Year of High School Graduation*
Were you home-schooled?*
Did you earn a GED?*
Did you take college courses while in high school?*
PART III. FAMILY INFORMATION
The information in this section, required of all applicants, is used to determine eligibility for participation in Student Support Services and will be treated confidentially. Last year’s Income Tax Return must be submitted to the Luther College Financial Aid Office.
I currently reside with*
If you responded guardian above, please specify relationship to you
Mother's educational background: (check only the highest level completed)*
Father's educational background: (check only the highest level completed)*
The income information below is essential to process your application. Please take the time to provide the correct information from your most recent tax return. Please note the figures requested are different than the ones from your FAFSA.
What is the size of your parents’/guardians’ household including yourself?*
Did your parents/guardians file a federal income tax return for 2013?*
If yes, what was their 2013 taxable income? If no, place a “0” in the answer box.*
TAXABLE INCOME IS FOUND ON IRS Form 1040: Line 43 or IRS Form 1040A: Line 27 or IRS Form 1040 EZ: Line 6.
PART IV: NEEDS LIST
Student Support Services wants to best serve your needs. Please take a moment to indicate those areas you may need help with as you make the transition from high school to college. Check all that apply.*
Your proposed major
Career interests
I plan to be involved in
PART V. SERVICES AND ACTIVITIES
Although we would like to offer services to everyone who is eligible, Luther College is only funded to serve 160 students in Student Support Services. Naturally, we want to provide services to students who will take advantage of them
GS110 CRITICAL READING AND LEARNING: Strategies for College Success. One of the main services we provide is a free, two-credit course which serves as the foundation for your learning and development for the next four years. The class meets twice a week during fall term.
Please indicate the services and activities in which you wish to participate. Check all that apply*
Can you think of anything that could keep you from completing your degree, such as family, grades, social life, money, motivation, career decision, etc.? Please describe
PART VI. AUTHORIZATION AND AFFIRMATION
This application must be signed before submitting. Check each box so we know you have read and understood the following:*
Your Electronic Signature*
Luther's Student Support Services project is funded by the U.S. Department of Education at $270,000 annually. The TRIO program has been in place at Luther for over 40 years and serves at least 160 Luther students each year. All services and activities are free to those who qualify.