If you are interested in becoming a participant, please print this form, complete and return to the following address:
Name: _______________________________________ SS#____________________
Student ID (if known) E____________________
Campus Address: ____________________________________ Phone: ____________________
Dorm Room or Street, Apt. #, City
Street, City, State, Zip
Phone: ______________________________ E-Mail:________________________________
Include Area Code
Male ___ Female ___
Marital Status: Single ___ Married ___ Divorced ___ Separated ___ Widowed ___
Birthdate _________________ Date entered ESU? _______________
American Indian/Alaskan Native___ Asian___ Black/African American___ Hispanic/Latino___
White/Caucasian___ Native Hawaiian/Other Pacific Islander___ More Than One Race___
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.
Date:________________ SS# ___________________
Please schedule an appointment (620-341-5097) to meet with the Director of Project Challenge one month before your first semester at ESU.