(Please fill out as much information as possible)
N.C. A&T STATE UNIVERSITY STUDENT SUPPORT SERVICES PROGRAM
STUDENT INFORMATION INTAKE DATA

NOTE TO STUDENT:  The information you give will be held in confidence by the Student Support Services staff.

Date:_____________________________

PERSONAL DATA:

Name______________________________________________________________ Soc. Sec. No.:______________________
(Last, First, Middle)

e-mail address:_________________________________

Campus Address (if known)_______________________________________________________________________________
(Box Number, Telephone Number, Dorm)

Home Address____________________________________________________  Phone:_______________________________

City________________________________________    State______________________    Zip________________________

Date of Birth:________________________________    Sex:    Male_________________    Female:____________________

Ethnic Background:    Black____________    White______________    Other (specify)_______________________________

Current Family Size:_______________________________    Family Adjusted Income:______________________________

Parent(s) graduated from a 4-year college or university:    Yes________    No___________

Parent(s) or Guardian(s) Name(s):__________________________________________________________________________

EDUCATIONAL DATA:

Cumulative High School Garde Point Average - Convert to 4.0 Scale:______________

College Grade Point Average (If Applicable)___________________

Former College Attended:________________________________________________________________________________

Current enrollment at A&T began__________________________
                                                    (Month & Year)

Academic Standing:    Freshman_________    Sophomore__________    Junior__________    Senior__________
                                Special Student______________

Have you previously participated in:    Upward Bound_________    Talent Search__________
                                                    Other (specify)_________________________________

How does your family feel about your attending college? (check one)
    They are:    Oppossed________    Don't Care________    Favorable________    Insistent_________

What is your present career choice?________________________________________________________________________

What career do (or did) your parent(s) want you to follow?____________________________________________________

After completion of the Bachelor's Degree do you plan to pursue the:
    (check all that apply)            __________Master's Degree        __________Doctorate Degree
                                            (M.S., M.B.A., M.A., M.L.S., Etc.)

Areas in which you feel you may need assistance or in which your training or skills may be somewhat inadequate for college
study.  Please check all that apply.

_____English Skills                            _____Study Habits                _____Tutoring
_____Personal-Social Counseling          _____Reading Skills                (indicate subject(s))
_____Writing Skills                           _____Financial Aid              _________________
                                                       _____Taking Exams            _________________
                                                                                                _________________
 

    I,______________________________________agree to participate fully in the Student Support Services Program and agree that the information provided by me is correct to the best of my knowledge.

    I authorize that office to obtain academic, financial aid and any other information pertinent to my participation in the Student Support Services Program.

                            Signed:_________________________________________________________