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Continuing Student Application

NOTE: If you have never applied to SSS before, you MUST fill out and complete the New Student Application on the Apply for Services page.

* Indicates a required field

First Name:
Last Name:
Student ID:
Gender:	Male Female
Local/Campus Mailing Address:
Phone Number:
Email: (userid@uncg.edu)
Parent/Guardian Name:
Parent/Guardian Phone Number:
Parent/Guardian Address:
Select Academic Year:	Fall 2009 Spring 2010
Current Enrollment Status:	Full Time 3/4 Time 1/2 Time Less than 1/2 Time
Classification:	Freshman Sophomore Junior Senior Other
Current Cumulative GPA:
Major:
Minor/Concentration:
Faculty Advisor:
Are you registered with the Office of Disability Services here on campus?:	Yes No
Service Request: Please complete the Request for Services form following this application.
Tutoring:
Study Skills:
Counseling:
Contract for Continued Services: (please read carefully) I understand it is an opportunity to participate in the Special Support Services Program. I understand that upon receiving services from this program, I accept the following responsibilities: To attend and arrive on time for all scheduled tutorial, counseling and academic skills sessions; To utilize at least one (1) of the three (3) components (tutoring, counseling, or academic skills) in addition to using the Learning Lab during each semester, in order to remain in good standing with the program; To attend all required counseling group sessions and academic skills workshops; To provide Special Support Services with up-to-date local or campus address and telephone number information, as well as any changes to permanent address or telephone information; To prepare for tutoring, counseling, and academic skills sessions by doing necessary and recommended activities and by attending classes regularly; To notify in advance my tutor, student success assistant, or other Special Support Services staff member when I am unable to keep an appointment and to reschedule promptly; To forfeit my participation in the Special Support Services program if I miss more than three (3) consecutive appointments without a valid reason and proper advance notification, or if I fail to comply with any of the above stipulations; I understand that I will have access to the Special Support Services Program at no cost. I also understand that my records will be treated confidentially by Program staff.
Information/Photo Release: I understand that my social security number is required for and will be obtained and handled confidentially by program staff for federal reporting purposes. I hereby grant permission to Special Support Services to obtain requested information from my personal file and student records (including enrollment,attendance, grades, financial aid, disability documentation, and student employment) for the purpose of helping me to succeed while enrolled at UNCG. I also hereby grant permission to Special Support Services to use photographs of me, taken during program events or by my pre-obtained permission during scheduled tutoring, counseling or academic skills sessions, for the program website or other publications. Information on this application is accurate to the best of my knowledge.
Please continue to complete the Request for Services Form

 

Page updated: April 21, 2009