First Name * Middle Initial Last Name * Student ID# Social Security Number * Program of Study/Major Gender * "-Select-"MaleFemale Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year194819491950195119521953195419551956195719581959196019611962196319641965196619671968196919701971197219731974197519761977197819791980198119821983198419851986198719881989199019911992199319941995199619971998199920002001200220032004200520062007200820092010201120122013201420152016201720182019 Age Street/P.O. Box * City * State * "-Select-"AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Marianas IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code * MCC Email Address Other Email Address Phone High School Graduate * Yes No GED * Yes No If GED, what year completed Are you a returning student to MCC? * Yes No Did you attend another college? Yes No Do you already have a college degree? * Yes No If you are a returning student enter Date(Semester/Year) you first enrolled in MCC: If so, state the degree title and granting institution: What type of degree are you pursuing? * Associate Diploma Certificate Do you plan to transfer to a four-year college? Yes No If yes, what college/university? Will you attend MCC - None -Part-time (less than 12 credit hours per semester)Full-time (12+ credit hours per semester) Date (Semester/Year) you first enrolled in MCC (not Dual Enrollment) If Yes, Name of College Citizenship: * US Citizen Permanent Resident Other (Documentation of Citizenship) Please identify your ethnic background (Select all that apply): Black or African-American Hispanic Asian Native American/Native Alaskan Native Hawaiian/other Pacific Islander White/Caucasian Is English your first language? Yes No If No, what language? Did either of your parents earn a bachelor's degree (BA/BS) from a college/university? * Yes No How many people are in your family (living under the same roof)? * Do your parents support you? * Yes No What are the sources of income for all family members? (Select all that apply) * Job income Alimony Child Support Daycare Disability/SSI DSS Medicaid Scholarships Social Security Food Stamps (SNAP) HUD Veteran's Benefits WIA/WAMY WIC Other If Other, what type of income: Are you receiving a Pell Grant? * Yes No Pell Grant amount $ Do you have a documented disability? * Yes No If Yes, please describe: Have you ever received accommodations for a disability in school? * Yes No If Yes, what accommodations? Do you think you might have a disability that could affect your college goal? * Yes No If Yes, please explain: Check the Areas in Which You Would Like Assistance: (Select all that apply) Academic Advising/Support Career Counseling Financial Counseling Math Assistance Personal Counseling Scholarships Stress/Time Management Study Skills Test Anxiety Transfer Advising Tutoring Writing Assistance What do you believe college with provide for you? * What help would you like from the S.O.A.R. Program? * What major have you chosen and why? What career opportunities are you aware of in this field? * What obstacles or challenges do you think you will face in your academic program? * By adding my name to this form-I hereby certify that the above information is true and correct to the best of my knowledge. I also grant permission for the S.O.A.R. Program of Mayland Community College to have access to my financial and academic records. If admitted to the S.O.A.R. Program, I understand that it is my responsibility and obligation to meet with my assigned counselor before withdrawing from college. Student Signature * Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year20162017201820192020 *Privacy Act and Non-discrimination policyIn accordance with the Privacy Act of 1974 (Public Law No. 93-579, 5 U.S.C. 552a), you are hereby notified that the Department of Education is authorized to collect information to implement the Student Support Services Program under Title IV of the Higher Education Act of 1965, as amended (Pub. Law 102-325, Sec. 402D). In accordance with this authority, the Department receives and maintains personal information on participants in the Student Support Services program. The principal purpose for collecting this information is to administer the program, including tracking and evaluating participant progress. Providing the information on this form, including a social security number (SSN) is voluntary; failure to disclose a SSN will not result in the denial of any right, benefit or privilege to which the participant is entitled. The information that is collected on this form will be retained in the program files and may be released to other Department officials in the performance of their official duties. **Mayland Community College prohibits discrimination and harassment in its educational services, programs and employment based on race, color, creed, religion, national origin, gender, gender identity, gender expression, sexual orientation, age, disability, genetic information and veteran status. Please see www.mayland.edu/titleix for more information.