SSS Participant Application & Enrollment Form

Thank you for your interest in our Student Support Services program! Please complete this application as thoroughly as possible.

You cannot save and restart this application. You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit your application. If you have any questions, please call our office at 517-264-7630.

General Information:

The information you are asked to provide is required by the U.S. Department of Education (DOE) for reporting purposes only. This demographic information will not impact your application for admission to SSS. In addition, the descriptions of race/ethnicity below reflect the DOE's Annual Performance Report race/ethnicity descriptions.

Fields listed as "optional" are not required by the DOE.

First Name *
Last Name *
Preferred Name (optional)
Pronouns (optional)
School ID Number
Gender *
Date of Birth: *
Describe your primary reason for applying: *
Are you a citizen or national of the United States or do you meet the residency requirements for Federal student financial assistance? *
Address: *
Address 2:
City: *
State: *
Zip Code: *
Email Address: *
Cell Phone Number: *
Do you have a documented disability? *
If you do have a documented disability, have you connected with Cody Mathis, Office of Accessibility? (If no, visit
Race/Ethnicity (Please select yes or no for each box)
Race, American Indian or Alaskan Native *
Race, Asian *
Race, Black or African American *
Race, Hawaiian or other Native to Pacific Island *
Race, White *
Ethnicity, Hispanic *
Please identify any campus communities you plan to be involved with. (e.g. Athlete, Band, Honors, Theatre, etc)

Academic Info:
Do you plan to go to graduate school? *
Current Grade Level: *
Why do you want to complete a college education? *
What are two goals that you hope to achieve after graduation from Siena Heights University? *

Family Information:

The information from this section allows us to determine student eligibility.

First-generation college student means an individual neither of whose natural or adoptive parents received a baccalaureate degree; or a student who, prior to the age of 18, regularly resided with an received support from only one natural or adoptive parent and whose supporting parent did not receive a baccalaureate degree.

If you are unaware of family information, please select "1" (one) to indicate Independent status under "How many people live in your household?"

How many people live in your household? *
Parents Educational Level: *

An individual whose family’s taxable income did not exceed 150% of the poverty level in the calendar year preceding the year in which the individual participates in the project. This amount is determined annually by the federal government.

A parent/guardian's signature is required for this portion of the application. If you believe you are an independent student, please contact our office at 517-264-7630. Please use your parent’s or your (independent students only) prior year (not prior-prior) federal tax return, to select the Family Income Range from the drop-down. This information can be located on the following forms: Form 1040 or Form 1040-SR– line 11b. For example, if you are applying for the 2020-2021 school year, you should use 2019 tax information.
Family Income Range:
Signature of Parent/Guardian *
Please select a signature verification type.
Are you interested in the Summer Scholars Program? (Applicable to first-time, first-year students)
Authorization Statement: I understand that information on this application will be used by the SSS Staff to assist in developing my academic, personal, or other relevant needs. I authorize the Student Support Services program staff to obtain any and all information and documentation necessary for processing and ongoing evaluation of these needs in pursuit of my degree at Siena Heights University. I understand that not meeting program expectations may result in the suspension of program privileges and/or termination from the SSS program. I give my consent for Student Support Services, and by extension Siena Heights University, to use my photograph and likeness for marketing and promotional publications, including its website.