Intake Form

If you are interested in becoming a participant, please print this form, complete and return to the following address: Emporia State University  Project Challenge  1200 Commercial St., Campus Box 4005 Emporia, KS  66801

Name: _______________________________________ SS#____________________

Student ID (if known) E____________________

Campus Address: ____________________________________ Phone: ____________________ 
                              Dorm Room or 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? _______________

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.

Signature: ___________________________________ 

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.