Student Support Services Application

NetID

First Name

Middle Name

Last Name

Birthdate

Are you a United States citizen or permanent resident?

Yes

No

Are you Pell eligible?

Yes

No

I'm not sure

Gender

Female

Male

What race(s) do you most closely identify with?

Native or indigenous tracing your ancestry to South America, North America or Central America, including American Indian and Alaskan Native

Asian tracing your ancestry to Southeast, East, Indian subcontinent, Cambodia, China, Japan, Korea, Malaysia, Pakistan, Philippine Islands, Thailand, Vietnam, etc.

Black, African, or African American tracing your ancestry to Africa

White or Caucasian tracing your ancestry to Europe, Middle East, or North Africa

Hawaiian or Pacific Islander tracing your ancestry to native peoples of Hawaii, Guam, Samoa, or other Pacific Islands

Do you identify as Hispanic or Latino?

Yes

No

Email Address

Phone

I am applying for academic semester:

Fall

Spring

For the year:

What is your student status?

What is your current cumulative GPA?

Permanent Mailing Address

Mailing Address

Country

Street

City

Region

Postal Code

Your Information

Please mark the highest level of education completed by your parents or guardians

Guardian #1

Guardian #2

Language other than English spoken by parents

Following graduation, do you plan to apply to graduate or professional school?

What graduate field or professional program?

Section A

Have you participated in any of the following programs?

Upward Bound?

Talent Search?

Educational Opportunity Center?

Student Support Services?

College Possible

Gear Up

Section B

Disability Status

Have you previously received accommodations (ex: IEP, 504 plan)?

Have you registered with Creighton's Office of Student Accessibility Services?

Section C

All students enrolled in the Student Support Services Program must have a need for services. Please check all items that apply. You MUST check at least one or more options to be eligible for this program.

Please tell us about your "ACT sub-score below 23:"

Please tell us about your areas of academic need:

Please specify your referral's name:

Have you been, or are you currently a foster child or ward of the state (before the age of 18)?

Section D

Please answer the questions listed below. Limit your response to no less than 150 and no more that 250 words for each question.

What can Student Support Services do for you? Why and how can SSS help you?

Tell us about a time you were able to achieve a goal. What was your goal? What behaviors or actions contributed to your success?

Tell us about a time you were unable to achieve a goal. What was your goal? What behaviors or actions prevented you from achieving your goal?

Tell us about the best day of your life

Additional questions, comments, statements, etc.:

Please upload a photo of yourself to include in your application file. This photo will also be used for our program directory if accepted to the program:

Section E

Financial Documentation

Please upload a signed copy of all pages of your parent/guardian(s) 2022 Tax Return as well as parent/guardian(s) W2 forms. This is information we will need to verify your eligibility for the program.

Click here to see a sample of the form needed

If your parents did not file taxes, please indicate this on the Dependent Verification worksheet that is linked below.

Dependent Verification Worksheet Form

Please click here to download a copy of the Dependent Verification Worksheet Form

Fill out the form, and then upload a completed copy below.

Student Support Services Application - Current Students