Request for Services Form

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University of Maryland Baltimore County

Student Support Services

Request for Services Form

Instructions for completing this form:

* Read each question carefully. Complete all sections in ink or type. If printed, please print legibly. If you fail to answer all necessary questions, your questionnaire will be returned to you for completion.

* Errors can cause lengthy processing delays.

* Any documentation must have student applicant’s name & Campus ID written on top of each page for proper identification. Documents cannot be returned because they become a part of the student’s permanent file.

* If you need any help answering these questions, please call our office at (410) 455-3250.

Section I. Request for Services

The information you provide on this form will be held in the strictest confidence.

Demographic Data

1. Name: _______________________________________________________________ Campus ID: ________________________

Last (Legal Name) First M.I

2. Address: ______________________________________________________________ Home Telephone: ________________________


City State Zip Code

Campus Address: _________________________________Campus Telephone: _________________Email___________________
3. Sex: (Please circle) Male Female Birth date: ________________________
4. Academic Level: (Please circle) Freshman Sophomore Junior Senior
5. Ethnic Background: (Please circle) White African American Hispanic Native American Asian/Pacific Islander
6. Are you a U.S citizen? (Please circle) Yes No (If you are not a U.S Citizen, please enclose a copy of your alien registration card)
First Generation

7. Have either of your parents/guardians (who reside with you) received a Bachelor’s Degree? (Please circle) Yes No

Physically Handicapped/Learning Disabled/Medical /Mental Health

8. Please check the item(s) below which you consider a disability to you.

If you check any condition (A-K) below, you must also complete Section IV.

You also must provide certification/documentation and attach to this application.

___ A. Sight impairment: partial, not correctable with normal lenses

___ B. Sight impairment: legally blind

___ C. Hearing impairment: significant bilateral hearing loss

___ D. Hearing impairment: deaf

___ E. Mobility impairment: use of wheelchair

___ F. Mobility impairment: other

___ G. Coordination impairment: loss of manual dexterity

___ H. Learning disability: reading ___ spelling ___ math ___ writing ____ A.D.D./A.D.H.D ____

___ I. Speech impairment

___ J. Systemic impairment (e.g.) seizures, diabetes, AIDS, other chronic/episodic medical condition

___K. Mental Health


9. How did you hear about Student Support Services?

___ Instructor ___ Talent Search ___ Admission Office

___ Registrar’s Office ___ Academic Advisor ___ Another UMBC Student

___ Upward Bound ___ SSS Staff: ___ Other

Name: ___________________ Specify: __________________

10. What is your main objective in requesting services from Student Support Services?

SECTION II - Student Personal Assessment.

Part A:

1. What are your objectives (What do you want to do in life)? _______________________________________________________________


2. What kind of student do you think you are (academically)? (Please circle) A B C D F

3. Do you have any special skills or talents? (Please circle) Yes No If yes, what? ______________________________________

4. What would you like to be doing professionally five years from now? _______________________________________________________

5. How can Student Support Services help you in accomplishing your goals? ___________________________________________________

6. What do you expect to gain from Student Support Services? _______________________________________

7. Can you think of anything that will interfere with your success while participating in Student Support Services?______________________


8. Do you have a part-time job? Yes________ No ______ If yes, where do you work? ____________________________________________

What is your work schedule? _________________________________________________________________________________

Part B:

Directions: Please read the following questions carefully. Answer each question as honestly as you can. This is NOT a test. If you have any questions about any of the following items, please request assistance before responding. For items 1-20, circle the number that corresponds to your response.

  1. How do you rate your ability to do well in courses that require good reading skills?

1. Above average 2. Average 3. Below average 4. Inadequate

  1. How do you rate your ability to do well in courses that require good reading writing skills?

1. Above average 2. Average 3. Below average 4. Inadequate

  1. How do you rate your present level of study skills and habits?

1. Excellent 2. Above average 3. Average 4. Poor

  1. How sure are you at this point of your career goal?

1. Positively Sure 2. Somewhat Sure 3. Not very Sure 4. Undecided

  1. How sure are you at this point that you have selected the major that you really want?

1. Very Sure 2. Somewhat Sure 3. Not Very Sure 4. Inadequate

  1. How do you rate your ability to do well in courses that require good math skills?

1. Above average 2. Average 3. Below Average 4. Inadequate

  1. How do you rate your ability to do well on objective examinations (True-False, Multiple Choice, Matching, etc)?

1. Above average 2. Average 3. Below Average 4. Poor

  1. How do you rate your ability to do well on essay-type examinations?

1. Above average 2. Average 3. Below Average 4. Poor

  1. How do you rate your high school preparation in mathematics?

1. Excellent 2. Good 3. Fair 4. Poor

  1. How do you rate your ability to comprehend what you read in your college texts?

1. Good 2. Average 3. Below Average 4. Poor

  1. How do you rate your ability to write research papers, essays, etc?

1.Good 2. Average 3. Below Average 4. Poor

  1. How do you rate your reading rate or speed of reading textbook material?

1. Good 2. Average 3. Below Average 4. Poor

  1. What grades do you think are capable of earning in college?

1. Mostly A’s 2. Mostly B’s 3. Mostly C’s 4. D’s & C’s at best

  1. What grades are you currently earning in college? (If first semester freshman, answer according to high school achievement.)

1. Mostly A’s 2. Mostly B’s 3. Mostly C’s 4. D’s &C’s

  1. What grades do/will you attempt to earn at UMBC?

1. A’s 2. A’s & B’s 3. B’s & C’s 4. C’s at best

  1. How important to you are good grades compared with other aspects of your college experience?

1. Most Important 2. Very Important 3. Important 4. Other aspects are more important

  1. How do you rate yourself in general ability as compared to your classmates?

1. Superior 2. Above Average 3. Average 4. Below Average

  1. Where do you think you rank among your classmates in reference to academic achievement?

1. Top of level 2. Near Top Level 3. Middle 4. Bottom

  1. How do you feel when you do not do as well as you know you can/

1. Very Badly 2. Badly 3. Don’t Feel Bad 4. Doesn’t Bother Me At All

  1. Do you think you have the ability & skills to complete your college requirements and earn a degree in the major of your choice?

1. Very Definitely 2. Probably, Yes 3. Not Sure 4. Probably, No
Part C:

Please indicate the level (1 – 5) to which you may need assistance in the following areas:

Assistance Desired: ( Low) 1 2 3 4 5 (High)

1. Selecting a career for the future ____

2. Knowing where to go for more career exploration ____

3. Selecting a major ____

4. Help in learning about University procedures such as dropping classes,

changing majors, changing advisors ____

5. Learning about requirements for various majors ____
Study Skills

1. Time Management ____ 5. Writing Skills ____

2. Notetaking ____ 6. Motivation Problems ____

3. Test Taking Strategies ____ 7. Test Anxiety ____

4. Reading Skills ____

1. Housing ____ 5. Health Problems: Nutrition,

2. Transportation ____ Drugs/Alcohol, etc ____

3. Relations with family/friends 6. Financial Problems ____

roommates, others ____ 7. Other Concerns: ____

4. Dealing with stress ____ list: ____________________________________________________________

SECTION III – Agreement to Participate
The purpose of this agreement is to communicate your responsibilities while participating in Student Support Services. We believe students should be aware of their responsibilities. Therefore, it is necessary for you to carefully read and sign this agreement.
I understand and agree to the following:
A. That my purpose of attending UMBC is to earn a baccalaureate degree.

B. That I am obligated to attend all schedule classes.

C. That I will accept all appointments and attend all meetings arranged through the Student Support Services offices: e.g., counseling, academic advising, tutoring, reading, writing, and study skills sessions, workshops.

D. That I will take a restricted course load, if advised to do so, and will accept assignment(s) to specific course(s).

E. That my academic progress will be monitored by the Student Support Services staff, and an up-to-date record of my academic work will be maintained.

F. That I will discuss any changes in registration with my SSS advisor prior to making the official change: e.g., dropping courses, adding classes, declaring a major, and withdrawing from the University.

G. That I will maintain regular contact with my SSS advisor, specifically during my first two years at the University of Maryland, Baltimore County.

H. That I will continue to participate in Student Support Services, based upon need, through graduation.

As a Student Support Services participant, I understand that I am eligible to receive:

1. Academic Advising

2. Academic Counseling

3. Personal/Career Counseling

4. Financial Aid Counseling

5. Tutorial Services

6. Assistance with Course Selection & Registration

7. Special Topics Workshops

8. Protection from Academic Dismissal during my first two years at UMBC, provided that I participate as required in the SSS.

I understand that the Student Support Services staff can assist me in achieving my academic career goal only if I fulfill my obligations. I also understand that failure to meet my responsibilities as required can result in suspension or termination from Student Support Services.

____________________________________________ ______________________

Participant Date
SECTION IV – Only students with disabilities should complete this section
Complete this section if you checked an item (A-K) in question eight of SECTION I.
1. Are you registered and receiving assistance from Vocational Rehabilitation or VA? Yes ______ No _____

If “YES”, may we contact your vocational Rehabilitation or VA Counselor? Yes ______ No _____

Counselor’s Name: ______________________________________________________________________________________

Address: _________________________________________________________ Phone Number: ________________________

2. If you have a specific learning disability, have you been diagnosed by a school psychologist or other competent specialist?

Yes ______ No _________

-If you answered “YES” to the above, it is necessary that SSS have a copy of your records concerning this disability. Will you sign a consent form for release of such information? Yes ____ No _____

-If you have not been diagnosed by a competent specialist, you must have this done as soon as possible in order to continue to receive accommodations services.

3. Type of Assistance needed:

Reading ______ Mobility Training ______ Tutoring ______

Note taking ______ Test Taking ______ Interpreting (ASL) ______

Other _________________________________________________________________

4. Use of equipment:

Visual Tek ______ Braille Writer _______ Optacon _________

Tape Recorder ______ Talking Book Machine _______ Talking Computer _________

5. Number of credit hours for which you are enrolled this semester: ________________

(Participants need to complete an accommodations card with your schedule at the beginning of each semester at UMBC)

Please attach your documentation of disability, including a diagnosis by a qualified professional as well as any testing results.

Student applicant’s name & Campus ID written on top of each page of documentation/attachments.

SECTION V – Income Information for Low Income Status

Student’s Name: _________________________________________________________ Social Security #: ___________________

Parent/Guardian :_________________________________________________________Social Security #: ___________________

Marital Status: Single ___ Married __ Divorced __ Separated ___

How many dependents do you (parents/guardians or independent student) claim? _____________________________

My total income (money that you earned) for 20____ was $ ________________ from the following sources:

Name(s) of employer(s):__________________________________________________________________________
In 20____, I received non-taxable income from the following sources:

____ Social Security benefits/How much per month? $______________ How many months? ____________________

____ Disability benefits/How much per month? $______________ How many months? ____________________

____ Welfare check/ How much per month? $______________ How many months? ____________________

____ Food Stamps (AFDC)/ How much per month? $______________ How many months? ____________________
I hereby swear and affirm that the information reported on this form and any attachment hereto is true, complete, and accurate to the best of my knowledge.
_______________________________________________________________ ______________________________

Signature of Parent/Guardian or Student (if independent ) Date

I understand that Student Support Services will use the data provided on this form to assist in assessing any academic and/or career planning needs and that all of the information will be used in the strictest of confidence. By signing this form, I understand that Student Support Services will also obtain a copy of my transcript from the Registrar’s Office.
___________________________________________________________________ _____________________________

Student’s Signature Date

The U.S. Department of Education’s approved income limit for a family of __________ is $___________________. The family’s verified taxable income is $ _____________________. Therefore, the student is classified as:

________ 1. First Generation/Low Income _________ 4. Physically Disabled

________ 2. First Generation _________ 5. Learning Disabled

________ 3. Low Income _________ 6. Other

Action Recommended: Accept: _________ Deny: _________ Add to Waiting List: ____________
_______________________________________________________________________ __________________________

Staff’s Signature Date

Action: Accept: ___________ Deny: ______________ Add to Waiting List:__________________
______________________________________________________________ _______________________________

Director’s Signature Date

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