EmailMe Form - Student Support Services Application

Legal Name *
First Middle Last
Chosen Name
First Middle Last
Preferred Pronouns (he/him, she/her, they/them, etc.) *
Gender *
Last 4 of Student ID *
Date of Birth *
MM / DD / YYYY
Mailing Address *

Street Address City State / Province / Region Postal / Zip Code
Cell Phone
### - ### - ####
Email *
Degree Program: *
Associate's (2-year)
Bachelor's (4-year)
Class Status: *
FR (0-29 credits)
SO (30-59 credits)
JR (60-89 credits)
SR (90+ credits)
Major: *
Minor:
Marital Status *
Single
Married
Single Parent
Divorced
Legally Separated
Widowed
U.S. Citizen *
Yes
No
Veteran *
Yes
No
Ethnicity *
Hispanic or Latino
Not Hispanic or Latino
Race *
American Indian or Alaskan Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
More than one race
Other
Have you already completed a first bachelor's (4-year) degree? *
Yes
No
At the time of your 18th birthday, did either of your parents have a Bachelor's Degree (4-year)? *
Yes
No
I'm Not Sure
If YES, what was the degree in (or their current occupation):
Do you have a diagnosed disability? *
Yes
No
If yes, please specify:
(You must provide us with documentation of your disability.)
Disability Documentation

Add File

*Can be provided to the Accessibility Services office at a later date.
On 2022 income taxes, were you a:
Dependent
Independent
For more information, visit: StudentAid.gov/dependency
Size of Family Unit
Income for 2022
Do (or will) you receive any of the following financial aid programs?
Yes
No
Not Sure
If YES, which one(s)?
Pell
FSEOG
Higher Ed
Veteran's Affairs
Welfare Aid
Social Security
Work-Study
Voc. Rehab
Student Signature *
Clear
I hereby grant permission to MSU-Northern Student Support Services to secure the necessary information pertinent to my participation in the SSS Program and MSU-Northern (e.g. financial data, standardized test scores, college/high school transcripts, instructor contact, and disability services). I certify the above information to be true to the best of my knowledge.
The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures on this agreement are the same as handwritten signatures for the purposes of validity, enforce-ability and admissibility. *
Yes, I agree
NOTE: All information requested in this form is confidential and used only to determine program eligibility and for SSS grant reporting. Only aggregate (total/subgroup) data will be used for purposes of federal grant compliance. Please note that you only need to apply ONCE to be considered for the TRIO SSS program.

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