Jenzabar University

Application for Services

Student Support Services is a federally funded program that provides academic support to a limited number of those who qualify. Acceptance of this application does not guarantee acceptance into the program. Chipola College is an affirmative action/equal opportunity institution.

Biographical Information

Chipola ID

Birth Date

Legal First Name

Legal Middle Name

Legal Last Name

Suffix

Preferred First Name

Gender

Marital Status

Ethnicity

Race (Choose one or more)

Is English your first language?

If no, what is your first language?

Select your US citizenship status

Resident Alien Number

Place of Employment

Hours worked per week?

Name, City, State of High School

Colleges Attended Before

Have you attended Chipola before this term?

How did you hear about SSS or who referred you?

What is your Major?

Academic Level

If seeking an AA degree, to what college/university do you plan to transfer?

Do you already have an Associate of Arts degree or higher qualification?

Have either of your parents or custodial/legal guardians, with whom you lived, received a Bachelor's Degree (4-year) in the U.S. before your 18th birthday?

Contact Information

Address Line 1

Address Line 2

City

County

State

Zip Code

Phone Number

Mobile Phone Number

Confirm Mobile Phone Number

Would you like to receive text messages regarding your application and important dates/deadlines?

By selecting yes, you agree to opt-in to Chipola College text message application alerts. These text messages will be limited to information about your application and important dates/deadlines. If you would like to opt-out of this program at any time, simply text the word STOP. Please be advised that message and data rates may apply.

Email Address

Confirm Email Address

Income Eligibility Documentation

All students in Student Support Services are required to apply for financial aid.

Have you applied for Financial Aid?

If yes, what is your status?

I have received my award letter and will be receiving?

List other awards you are receiving not listed above

What is your dependent status?

My Annual family TAXABLE income for last year

Number in family/household

Physical/Learning Disability Documentation

Do you have a physical or learning disability which requires special accommodations for you to succeed academically, and about which you would like to voluntarily give information for purposes of coordinating our services with the Disability Support Services office if appropriate?

A copy of any document that states the type/extent of your disability must be submitted to the SSS office or on file in the Chipola Disabilities Office if you desire any form of accommodation.

What is your disability?

Have you signed up with Chipola's Disability Office in the Student Services building?

Needs Assessment

Check the services you need

Motivational Assessment

Why do you wish to be a participant in SSS?

Describe your short term goals

Describe your long term goals

Confidentiality Statement: All information provided is kept confidential and is shared among the SSS staff and other college officials only on a need-to know basis. The following limits to confidentiality apply: when child/elder abuse is disclosed, when a threat to self or others is disclosed, or when records are legally subpoenaed.

Affidavit/Release of Information: I certify that the information I have provided on this application is, to the best of my knowledge, complete and accurate. I hereby authorize the SSS program to obtain academic and financial aid records that will help in assessing my academic and career planning needs. I understand, in order to confirm or facilitate transfer and graduation, my information may be shared with other post-secondary institutions. I also authorize the SSS program to print my name and photograph, as appropriate in articles in the SSS newsletter and promotional materials.

By typing my name in this textbox, I am accepting the terms and conditions outlined in the verification statement.

Student Name

By typing my name in this textbox, I am accepting the terms and conditions outlined in the verification statement.

Parent/Guardian Name