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First Name*

Last Name*

Email*

Z-Number*

Major*

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Street Address*

City*

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ZIP Code

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Cell Phone*

Home Phone*

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Are you a transfer student?*

Yes

No

Do you live on campus?*

Yes

No

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Why do you want to join the Student Success Scholars Program?*

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Grade Level*

Freshman

Sophmore

Junior

Senior

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Please check the following areas you would like support and/or information*

Time Management

Stress Management

Test Anxiety

Note-Taking Skils

Writing Skills

Internship/Study abroad/Leadership

Graduate/Professional school preparation

Academic Policies/Procedures

Graduation Requirements

Financial Aid Procedure/Assistance

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Do you plan on working during the semester?*

Yes

No

If yes, how many hours per week?

Doing what job?*

Where do you work? (How long a commute do you have?)*

What other responsibilities do you have that require your time?*

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Have you made your career/major choice?*

Yes

No

If yes, what is your career/major choice?

What led you to make your decision?*

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What services offered by the Student Success Scholars Program interest you most? *

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