Demographic Data

Your full name:

Social Security Number Birth date

Your email address: (e.g.: you@aol.com)

Home

 Your home phone number (with country, city, area codes):

Address:
City/Town:	State/Prov.: Post./Zip Code:
Country:

School

 Your local phone number where you can be contacted

Address:
City/Town:	State/Prov.: Post./Zip Code:

Contact

Name, Address, Phone# of a person who will always know where you are:


Your Sex:   Male   Female

Marital Status:   Single   Married   Divorced   Separated

Race:   White   African American   Hispanic American   Native American
            Other

Are you a U.S. Citizen?:   Yes   No   Permanent Resident

First Generation

Has either of your supportive parents/guardians up until age 18 received a Bachelor's degree
(a degree from a 4 year college)?  Yes   No

 Income Eligibility

Are you self-supporting? Yes   No     Are you supported by a parent/guardian? Yes   No

How many people are in your family     Family Taxable Income (from last year) $
                                                                 (final adjusted amount on which taxes are paid, not AGI)

OR Amount of Taxes Paid $

Academic Status

Incoming Freshman   Returning Freshman   Returning Sophomore   Graduating Sophomore

Graduation planned from NCCC? Yes   No Transfer planned to a 4-year institution? Yes   No

If so, name of institution?

Have you applied for financial aid using the Free Application for Federal Student Aid? Yes   No

Pick all that apply to you: Single Parent   Non-Traditional Student

Assessment Data

In which of the areas listed below do you need assistance? (Pick as many as apply)

Writing Skills   Financial Aid Advising   Reading Enhancement   Mathematics

Study Skills   Career Advising   Academic Advising   Personal Counseling

 Do you have a disability? Yes   No

(Auditory Disability / Visual Impairment / Physical Disability / Learning Disability / Other Disability)

Is this a documented disability? Yes   No

Is documentation on file at NCCC? Yes   No

If not are you willing to provide documentation to NCCC? Yes   No

Is there anything else that we should know in order to assist you in achieving your academic goals?

Educational Data

 Name of High School Attended:

Address:
City/Town:	State/Prov.: Post./Zip Code:
Country:

Year Graduated:     Year Completed GED:

Have you taken the COMPASS test? Yes   No

Have you taken ACT or SAT? Yes   No    If so, have the scores been sent to NCCC? Yes   No

Have you ever been a participant of a TRIO Program at another Institution? Yes   No

Talent Search   Upward Bound   Student Support Services   Other

Name of Institution:

Student Clearance & Approval

I understand that the STARS program will use the data provided on this form to assist in assessing academic and/or career planning needs and that all information will be kept confidential. I release the following information to the STARS staff: high school and college transcripts, COMPASS/ACT/SAT scores, NCCC graduate reports, financial assistance, award notices and income information, vocational rehabilitation records and any other information from my academic records pertaining to my enrollment in STARS.

Are you willing to give permission for the STARS program to publish any photos taken at NCCC or STARS activities for the program brochure and webpage? Yes   No

Entering your name and the date below acts as your on-line signature:

Name:     Date:

Notice of Non-Discrimination: Neosho County Community College does not discriminate on the basis of race, color, national origin, sex, age or handicap in admission or access to, or treatment or employment in its programs and activities. If you have any questions regarding the above, please contact: The Title IX and section 504 Coordinator at Neosho County Community College, 800 West 14th Street, Chanute, KS 66720. Telephone (620) 431-2820 ext. 279.

Members of the STARS staff are available to meet with you during the hours of 8AM-5PM Monday-Friday,
in the NCCC Panther Cave.


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