Student Support Services Electronic Application

Please complete the entire application before submitting.

Student Support Services Application

First Name

Last Name

Middle Initial

Birthdate

Rose State College Student ID Number

Mailing Address

City

State

ZIP Code

Cell Phone Number

Alternate Phone Number

Rose Email Address name@mail.com

Preferred Email Address

U.S. Citizen? *

Yes
No

Gender

Male
Female

Which of the following best describes your ethnic group?

African American
American Indian or Alaskan Native
Asian
Caucasian
Hispanic
Native Hawaiian or Pacific Islander
Other (specify below)

If you chose "Other" for ethnic group above, please specify here.

Marital Status

Single
Married
Divorced
Other

Number of Dependents

Ages of Dependents

Secondary Education

High School Diploma
High School Equivalency Exam
Neither

High School Graduation Year

Have you attended any colleges other than Rose State? If yes, where?

Do you plan to earn a certificate or Associates degree?

Yes
No

Major

Do you plan to pursue a bachelor's degree?

Yes
No

If you plan to pursue a bachelor's degree, what will be your major?

Did one of your legal guardians graduate from college with a Bachelor's degree?

Yes
No

Have you completed the FAFSA?

Yes
No

Are you receiving financial aid? You will be asked to provide financial documentation to determine program eligibility.

Yes
No

Do you have a disability?

Yes
No

How did you hear about Student Support Services?

Class Presentation
Instructor
Brochure/Flyer
Student
RSC Website
Other

Have you previously participated in a TRIO program?

Yes
No

If you have previously participated in a TRIO program, which program(s)?

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230 South LaSalle Street, Suite 7-500, Chicago, Illinois 60604-1411
Phone: 800.621.7440 / 312.263.0456 | Fax: 312.263.7462

Rose State College

6420 S.E. 15th Street Midwest City, OK 73110

Phone: 405-733-7673 | Toll Free: 866-621-0987