Self-Reported Identification Place a check mark next to the ethnic background(s) with which you most clearly identify: American Indian or Alaskan Native Tribe: _____________________________ Asian Native Hawaiian/Other Pacific Islander Black, African American Hispanic/Latino White/European American Emergency Contact _____________________________________________________________________________________ Name: Last First M.I. _______________________________________ ______________________________________________ Relationship to Student Cell or Home Number Eligibility Are you a first generation college student (neither parent completed a 4 year college degree)? Yes No Are you a United States Citizen? Yes No Are you a United States National (Native of American Samoa or Yes Swain’s Island)? No Are you a United States Permanent Resident (Registered with Immigration and Naturalization)? Yes No Do you have a documented, permanent disability? Yes No Are you registered with EXCEL? Yes No Applied Other Services Are you registered with Accessibility Services? Yes No Are you registered with GANAS? Yes No Are you registered with SANKOFA? Yes No Are you registered with SSOS or TAPASS? Yes No
Self-Reported Identification Place a check mark next to the ethnic background(s) with which you most clearly identify: American Indian or Alaskan Native Tribe: _____________________________ Asian Native Hawaiian/Other Pacific Islander Black, African American Hispanic/Latino White/European American Emergency Contact _____________________________________________________________________________________ Name: Last First M.I. _______________________________________ ______________________________________________ Relationship to Student Cell or Home Number Eligibility Are you a first generation college student (neither parent completed a 4 year college degree)? Yes No Are you a United States Citizen? Yes No Are you a United States National (Native of American Samoa or Swain’s Island)? Yes No Are you a United States Permanent Resident (Registered with Immigration and Naturalization)? Yes No Do you have a documented, permanent disability? Yes No Are you registered with EXCEL? Yes No Applied Other Services Are you registered with Accessibility Services? Yes No Are you registered with GANAS? Yes No Are you registered with SANKOFA? Yes No Are you registered with SSOS or TAPASS? Yes No
project-impact-application-revised-4-16-18.docx