Student Application Form - Success Scholars Program

* required information

First Name*

Last Name*

Email*

Z-Number*

Major*

.

Street Address*

City*

State

ZIP Code

.

Cell Phone*

Home Phone*

.

Are you a transfer student?*

Yes

No

Do you live on campus?*

Yes

No

.

Why do you want to join the Student Success Scholars Program?*

.

Grade Level*

Freshman

Sophmore

Junior

Senior

.

Do you plan on working during the semester?*

Yes

No

If yes, how many hours per week?

Doing what job?*

Where do you work? (How long a commute do you have?)*

What other responsibilities do you have that require your time?*

.

Have you made your career/major choice?*

Yes

No

If yes, what is your career/major choice?

What led you to make your decision?*

.

What services offered by the Student Success Scholars Program interest you most? *

.

Would you prefer a mentor who is LGBTQIA+ or supportive and knowledgeable of the LGBTQIA+ community?*

Yes

No

To print this form:

Please use your browser's print command from the file menu.