Thank you for your interest in Disability Support Services (DSS). Please complete this application as thoroughly as possible. You cannot save and restart this application, so you may want to review the included items and gather any information needed to accurately answer the questions below.

If you have any questions about this application, please call (316) 978-5949, email trio.dss@wichita.edu, or stop by our office in the Shocker Success Center #223 (main campus).

General Information:

First Name *

Middle Name

Last Name *

WSU ID *

Date of Birth *

Gender *

Address *

Address Line 2

City *

State *

Zip *

Cell Phone Number *

Email Address *

Ethnicity/Race *

If multi-racial was selected, please list them here

Eligibility Information:

U.S. Citizen *

Do you have a documented disability? *

Highest Level of Education that Your Parent(s)/Guardian(s) Completed:

Mother/Guardian *

Father/Guardian *

Have you completed the FAFSA? *

Are you receiving a Pell grant? *

Academic Information:

Class Standing *

Are you a transfer student? *

Are you currently on academic probation? *

Enrollment Status *

Number of credit hours enrolled in: *

Do you plan to earn a bachelor's degree from WSU? *

Major *

What is your target graduation date? (semester/year) *

The following are important issues relevant to your success at WSU. Please identify areas you would like assistance with or would like to learn more about.

Academic Advising & Support

Tutoring

Financial Aid Information

Personal Finance/Budgeting

Career Readiness/Guidance

Graduate School Information/Assistance

Study Skills Development

Personal Advising/Stress Management

University Resources and Services

How can TRIO DSS help you in accomplishing your educational goals?

What is your primary reason for applying to TRIO DSS? *

Acknowledgements and Authorization

To the best of my knowledge, all the information provided on this application is true and complete. I understand that TRIO Disability Support Services will use the information provided on this form to assist in determining eligibility and all information will be kept confidential. I understand that this TRIO DSS application is an educational record as that term is defined under the Family Education Rights and Privacy Act (FERPA).

I authorize TRIO DSS to obtain my academic records, including high school and/or college transcripts, course registration, grades, and other information necessary to provide the services I have requested.

I give my permission to release my name and/or photo to provide recognition in the TRIO DSS newsletter, website, and other publications, and to Wichita State University staff in the performance of their duties.

Are you registered with the Office of Student Accommodations and Testing (OSAT)? *

If yes, I authorize TRIO DSS to verify my disability documentation submitted with the WSU Office of Student Accommodations and Testing.

OR

You may upload your documentation of disability here:

Student E-Signature *

Signature Type: Simple Start Over

Signature: (Type in your full name)

I agree to the terms included.