Intake Form

Name: ____________________________________________ SS#___________________

Campus Address: _________________________________ Phone: __________________
                                Street, Apt. #, City

Permanent Address:__________________________________________________________
                                            Street, City, State, Zip

Phone: ______________________________  E-Mail:______________________________
                  Include Area Code

Male ___ Female ___ 
Marital Status: Single ___  Married ___ Divorced ___  Separated ___ Widowed ___

Birthdate _____________  Date entered ESU? _______________

Caucasian ____ African-American ___ Hispanic ___ Asian/Pacific Islander ___
Native American/Alaskan Native ___ Other ___

1.  Are you a U.S. citizen?  Yes ___  No ___

2.  Did your mother receive a 4-year college degree?  Yes ___  No ___
     Did your father receive a 4-year college degree?  Yes ___  No ___

3.  Have you applied for financial aid?  Yes ___  No ___

4.  Do you have a disability which would cause you to benefit from services? Yes ___  No ___

5.  Have you ever been in another TRIO program? Yes ___  No ___

6.  Declared Major: ______________________  Classification: fr. __ soph. __ jr. __ sr. __

7.  If transfer student, what school have you transferred from ________________________
and how many hours are you transferring to ESU ____________.

8.  What services will you use as a participant in the Project Challenge Program? __________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

CONFIDENTIAL FINANCIAL INFORMATION:

*  (A copy of last 1040 federal tax form filed must be attached.  Your parents' if dependent or yours if independent.)

Father's Occupation: ____________________________________________
(Your own if self-supporting)

Mother's Occupation: ___________________________________________
(Your spouse's occupation if self-supporting and married)

Size of Family (all members supported by family unit): _______________

If a tax return is not filed, please complete the following:
  Amount earned last year $ _____________
  Number in family unit _____________

RELEASE OF INFORMATION STATEMENT

I give permission to Student Support Services - Project Challenge to have access to any and all educational records, financial aid records and/or disability documentation needed to meet federal requirements for documentation and assessment.  I understand this information will be for program use only and will be kept confidential.

I give my permission to use photographs, quotes, academic accomplishments, statements and/or print my first and last name in any and/or all publications for Project Challenge.

Signature: ___________________________________ 

Date: _______________ SS# _______________
 

Last Updated April 30, 2007