* 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.
* Anydocumentation must have student applicant’s name & Campus ID written on top of each page for properidentification. Documents cannot be returned because they become a part of the student’s permanent file.
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)
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
8. Do you have a part-time job? Yes________ No ______ If yes, where do you work? ____________________________________________
What is your work schedule? _________________________________________________________________________________
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.
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 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 How do you rate your present level of study skills and habits?
1. Excellent 2. Above average 3. Average 4. Poor How sure are you at this point of your career goal?
1. Positively Sure 2. Somewhat Sure 3. Not very Sure 4. Undecided 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 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 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 How do you rate your ability to do well on essay-type examinations?
1. Above average 2. Average 3. Below Average 4. Poor How do you rate your high school preparation in mathematics?
1. Excellent 2. Good 3. Fair 4. Poor How do you rate your ability to comprehend what you read in your college texts?
1. Good 2. Average 3. Below Average 4. Poor How do you rate your ability to write research papers, essays, etc?
1.Good 2. Average 3. Below Average 4. Poor How do you rate your reading rate or speed of reading textbook material?
1. Good 2. Average 3. Below Average 4. Poor 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 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 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 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 How do you rate yourself in general ability as compared to your classmates?
1. Superior 2. Above Average 3. Average 4. Below Average 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 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 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:
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 ____
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.
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 _____
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.
FOR OFFICE USE ONLY
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
FOR DIRECTOR’S USE ONLY
Action: Accept: ___________ Deny: ______________ Add to Waiting List:__________________