SOUTHEASTERN OKLAHOMA STATE UNIVERSITY
SSS: Teach
425 West University Boulevard
Durant, Oklahoma 74701
SSS_Teach@se.edu

Thank you for your interest in our Student Support Services program for K-12 Teacher Preparation, known as SSS: Teach. 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 them return to submit your application. If you have any questions, please call our office at (580) 745-3304.

GENERAL INFORMATION

Last Name: *

First Name: *

Middle Name:

Student ID Number: *

Date of Birth: *

Gender: *

Marital Status: *

Permanent Address: *

City: *

State: *

Zip Code: *

Cell Phone: *

Home Phone:

Best Time to Call:

Student Email Address *

Personal Email Address *

Have you been a part of a TRIO program before? [Upward Bound, Talent Search, SSS, EOC, VUB] *

Have you met with an SSS: Teach advisor? If so, with whom?

Where or from whom did you hear about this program?

Emergency Contact Name

Emergency Contact Phone Number

ETHNICITY

Are you of Hispanic descent? *

Race: Please mark all that apply.

American Indian or Alaskan Native *

Asian *

Black or African American *

Hawaiian or other Native to Pacific Island *

White *

ELIGIBILITY

Are you a U.S. Citizen or permanent resident? *

Have either of your parents completed a four-year bachelor's degree? *

Do you have a documented disability? *

Disability Accommodations at Southeastern: Any student needing special accommodations due to a disability should contact the Office of Disability Services, GDJ Student Union Room 328 or call (580) 745-3036. It is the responsibility of each student who anticipates or experiences barriers to their academic experience to make an official request for disability related accommodations in a timely manner. If you have questions regarding disability accommodation process or policy please contact disabilityservices@se.edu for more information.

If you receive services from an off-campus office (i.e. Vocational Rehabilitation), please contact us about obtaining a letter from that office.

EDUCATIONAL INFORMATION

Have you completed your FAFSA for this year? *

Intended Major/Career Field: *

Are you registered for classes? *

What is your educational goal? (mark all that apply):

Bachelor's degree

Master's degree

Doctoral degree

ACT Composite Score

High School Attended: *

Diploma Date:

What College(s) have you previously attended (list all): *

Are all transcripts on file at SE? *

How many hours of college credit have you earned?

What degree or certificate have you received?

NEED FOR SERVICES

What do you see as your biggest challenge(s) or potential obstacle(s) this semester/year? *

What specifically would you expect our office to assist you with in order to achieve your goals? *

SERVICES AVAILABLE

Please check all SSS: Teach services you are interested in.

Academic Advisement/Enrollment

Tutoring Services

Financial Aid Assistance

Culturally Enriching Experiences

Financial/Economic Literacy

Personal Counseling

Portfolio (Chalk & Wire) Assistance

Educational Applications

Professional Development

Certification Test Preparation (OGET, OSAT/PRAXIS, PPAT)

Other service or assistance you would like:

INCOME VERIFICATION

As a federally funded TRIO program, SSS: Teach is required to provide documentation of a Student's eligibility for the program to the U.S. Department of Education and implement the TRIO Regulations that state two-thirds of the students served must meet federal low-income guidelines.

All applicants must complete this section whether or not you believe you qualify as low-income. Verification requirements for TRIO vary depending on whether students are independent or dependent.

To determine whether you are a DEPENDENT or an INDEPENDENT student, please answer the following:

Were you at least 24 years old by December 31st? *

Are you a veteran of the U.S. Armed Forces? *

Are you married? *

Are you an orphan or a ward of the court, or were you a ward of the court until age 18? *

Do you have any legal dependents (other than a spouse), such as children or parents who get more than 1/2 their support from you? *

If you answered NO to every question, you are considered DEPENDENT. Please upload one of the following:

A SIGNED, DATED copy of your Parent(s) or guardian(s) most recent Federal Income Tax Return, OR
A document with the statement: "I certify that my parent's TAXABLE INCOME from all sources in the previous tax year was $_________ with a family size of ____ (include your parents and their dependents). By signing this document, I attest under penalty of perjury that the above statement is true and correct." SIGNED, DATED by you AND your parent. (The Taxable Income Information can be found on the most recent IRS 1040 form line 15.)

If you answered YES to any question, you are considered INDEPENDENT. Please upload one of the following:

A SIGNED, DATED copy of your most recent Federal Income Tax Return, OR
A document with the statement: "I certify that my TAXABLE INCOME from all sources in the previous tax year was $_________ with a family size of ____ (include yourself, spouse, and dependents). By signing this document, I attest under penalty of perjury that the above statement is true and correct." SIGNED, DATED by you. (The Taxable Income Information can be found on the most recent IRS 1040 form line 15.)

Upload your Income Verification document(s) here:

By signing below, I agree to the following program requirements:

meet or correspond with my assigned SSS: Teach advisor at least 3 times per semester
attend at least 2 program services, workshops, or activities each semester
complete the FAFSA each year as an undergraduate
attend all scheduled classes, both in person and on Canvas, and routinely check my student email
notify the SSS: Teach office when my contact information changes or if I change my course enrollment
attend tutoring and/or meet with the Student Success Coach when prescribed by my SSS: Teach advisor

By signing below, I authorize the SSS: Teach program to obtain, copy, review, and discuss education records and other materials necessary for participation in a Student Support Services program.

I understand that the SSS: Teach program reserve the right to admit or deny any student enrollment in the SSS: Teach program. Completion of the application does not guarantee acceptance into the program. I also certify that all of the above information is true and correct to the best of my knowledge. I give the SSS: Teach program permission to use my statements, images, voices, or combination of these in promotional items (i.e. brochures, web sites, etc.) Furthermore, I understand that further documentation of income may be needed and all my records will be kept in confidence in accordance with the Federal Education Rights and Privacy Act (FERPA), codified at 20 USC 1232g.

I verify that I am at least 18 years of age, I have read this release and am fully familiar with the contents.

Notice of Non-Discrimination
Southeastern Oklahoma State University does not discriminate on the basis of race, color, national origin, or age in its programs and activities. The following person has been designated to handle inquiries regarding the non-discrimination policies: Title IX Coordinator, 425 W. University Blvd, Durant, OK 74701, 580.745.3090.

SIGN and SUBMIT

Applicant's Signature *

Please select a signature verification type.

Please scroll to the bottom of this page and click, "Submit Application" to submit your application.

If you fail to click the "Submit Application" button below, your application WILL NOT BE SUBMITTED. If you have fully submitted this application, you will be redirected to a confirmation page. Failure to fully submit your application will require you to restart this application from the beginning.