Please click here to see the eligibility requirements before applying.

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Permanent Address

Personal Information


By checking below you agree to the following: I wish to participate in the Student Support Services Program in order to achieve my educational goals. I agree to participate in all recommended services and will keep all scheduled appointments to help achieve these goals. I give SSS permission to secure any participation and to determine an effective academic plan. Information deemed appropriate may be obtained through correspondence with the Financial Aid Office, Office of Disabilities, JTPA, Rehabilitation Services or other educational information. I give the SSS advisor consent to have verbal and written contact with any of my professors regarding my academic progress in their class. The pertient information reviewed will included class attendance, preparedness and academic progress. I agree that the information I provided on this application is true to the best of my knowledge.

Please do not fill out the following field:


NOTE: The information requested in this form is used strictly to determine program eligibility as well as to provide program demographics to the Department of Education. ALL information will be kept in confidence by program staff. The JBU Student Support Services Program does not discriminate on the basis of ethnicity, gender, age, national origin or disability.