Upcoming events

Monday, 22 Sep

SSS-Health Sciences Self-Care Workshop
12:00 PM to 12:30 PM, September 22, 2014

Thursday, 25 Sep

Fallfest
11:00 AM to 02:00 PM, September 25, 2014

Tuesday, 30 Sep

SSS-Health Sciences Job Search Workshop
04:00 PM to 04:30 PM, September 30, 2014

Wednesday, 1 Oct

SSS-Health Sciences Identity Theft Workshop
12:15 PM to 12:45 PM, October 1, 2014

SSS - Health Sciences Application

Please fill out the following form:

* Name:
Amarillo College ID Number:
* Date of Birth:
* Age Now
* Sex:
Male
Female
* Marital Status:
Maiden Name:
* Current Home Address:
Apartment Number:
* City/Town
* State:
* Zip Code:
* Permanent Address:
* City/Town:
* State
* Zip Code:
Current Home Telephone:
Cell Phone:
* Email Address:
Alternate Contact:
Relationship to you:
Phone Number:
* Ethnicity:
Hispanic
Not Hispanic
* Race:
African-American
Asian
Caucasian
Native American
Native Hawaiian or other Pacific Islander
Other
If Other, please list:
* Check here if you were previously enrolled in Student Support Services (SSS).
Yes
No
If so, where?
Year?
* Are you currently enrolled this semester at Amarillo College?
Yes
No
* Are you a U.S. Citizen?
Yes
No
If not, are you a permanent resident of the U.S.?
Yes
No
Are you here on a student visa?
Yes
No
* Income verification will be required (either a signed/dated FAFSA or signed/dated tax return)

Do you currently file your income taxes independently or do your parent(s) / spouse claim you as a dependent?
Independent
Dependent
N/A do not file income taxes
If you are claimed as a dependent, who currently claims you?
Parent(s)
Spouse
* Family / Household Income:
* per
Month
Year
* Size of household (including yourself and any children you support 50% or more of the time)
* Have you filled out a FAFSA for the current year?
Yes
No
* Are you employed?
Yes
No
If not, do you plan to work soon (within the next few months)?
Yes
No
If yes, where are you employed?
Work Phone Number:
How many hours per week do you work?
1-5
6-10
11-20
21-30
31+
* Are you currently receiving financial aid?
Yes
No
If yes, please describe:
* Have either of your parents/guardians received a 4-year college degree?
Yes
No
* Do you have a physical or learning disability?
Yes
No
If yes, please describe:
Is your disability documented in the disAbility Services Office at Amarillo College?
Yes
No
* How did you learn about the SSS Health Sciences Program at AC?
Class visit by SSS Staff
Phone call from SSS
Faculty / Staff
Email from SSS
SSS Website
Other Students
Flyer / advertisement
Program, workshop, study session
Other
If Other, please explain:
Please mark ALL that apply to you:
Inadequate high school training
Earned a GED
Unprepared for college level courses
English is second language
Low GPA
Low GPA in courses for major
Poor study skills
Trouble understanding/communicating with instructor(s)
Away from school for 5 or more years
Want to raise grades in required courses
Want more support with academic course(s), such as tutoring
N/A, none apply
Other
Other
Please mark the services you would be interested in receiving (check each one of interest)
Academic advising
Direction with educational goals
Job shadowing opportunities
Direction with career goals
College survival skills
Communicating with instructors
Coping with stress
Discovering my learning style
Financial Aid counseling
Assistance completing FAFSA
Financial literacy/money management
Finding/applying for jobs
Interviewing for jobs
Memory techniques
Note taking
Organizational skills
Resume writing
Study skills
Test anxiety
Time management
Transfer to a 4-year school
Help applying to a 4-year school
Financial aid info from 4-year school
Tutoring in AC courses
Using textbooks
Writing skills
Other
Educational Information

Name of high school from which you graduated
* Year of graduation
If not a high school graduate, do you have a GED?
Yes
No
Year GED Obtained:
* When did you first start at Amarillo College? (If you do not know the exact date, please provide your best guess of the month and year)
* When do you expect to complete your studies at Amarillo College?
* What is your major at Amarillo College?
* Career Plans

What are your plans after completing your current degree (choose all that apply)?
Obtain an associate's degree from AC
Work
Continue my education at a 4-year university
Work while continuing education
If you chose work, in what field do you plan to work?
If you chose "continue my education at a 4-year," which schools are you considering?
Where?
What would you like to see yourself doing 5 years from now?
* In your own words, please explain briefly why you want to participate in the SSS Health Sciences Program.
* All information on this application is true and correct to the best of my knowledge.

I authorize SSS Health Sciences staff to verify information I have provided to qualify for the SSS Health Sciences program and to gather any other information or data needed (such as grades, financial information)to extend program services.


Yes
Refresh words by clicking Recycle button