Student Support Services Program Application

Thank you for applying to the Student Support Services Program at Rider University. Our program offers a range of services that are designed to increase the performance, retention, and graduation rates of students. The information requested in this application enables us to document your eligibility and establish your personal record. Completion of this application and submission of your parent’s/guardian’s IRS 1040 tax form (your own, if you are an independent student) is necessary for acceptance into the program. All information provided will be kept CONFIDENTIAL.

If you have any questions, please contact Dana Lopes at dlopes@rider.edu or 609-895-5615.

Student Demographic Information

First Name

Preferred/Lived Name

Last Name

Bronc ID

Gender

Birthdate

Home Phone Number

Mobile Phone Number *

Email Address

Home Address

Country

Street

City

Region

Postal Code

Are you Hispanic or Latino?

Yes

No

Regardless of your answer to the prior question, please check one or more of the following groups in which you consider yourself to be a member:

Marital Status

What is your dependency status?

Do you have any dependents? (children)

Yes

No

How many? What are their ages?

Are you a U.S. citizen or legal permanent resident?

Yes

No

Armed forces status

Please specify

Household Size (Include Self)

Parent / Guardian Information

Parent’s/Guardian’s Name:

Parent’s/Guardian’s Telephone #

Is your Parent's / Guardian's address the same as yours?

Yes

No

Parent’s/Guardian’s Home Address

Country

Street

City

Region

Postal Code

Have either of your parents attained a 4-year college degree?
Mother

Yes

No

Father

Yes

No

Academic Information

I will be a Rider

On-campus Resident

Commuter

Campus Address (if known)

Are you an athlete at Rider?

Yes

No

Are you a Milestones Scholars Program student?

Yes

No

Are you an EOP (Educational Opportunity Program) student?

Yes

No

Are you a transfer student?

Yes

No

Which college did you transfer from?
(Include Name, Location, & Major)

Date of Entry at Rider University

Status/Year Classification:

Number of credits completed

Cumulative GPA

Major (Please write "undeclared" if no major has been chosen yet)

Expected graduation date?

Have you ever been dismissed from Rider?

Yes

No

Please explain

Do you have any conditions that may be considered disabling or require accommodation? (optional)

Yes

No

SSS Program Questions

Why are you interested in participating in the Student Support Services Program?

What services are you interested in receiving?

Are you submitting the IRS 1040 Tax Form with this application?
(Submission of your parent’s/guardian’s IRS 1040 tax form (your own, if you are an independent
student) is necessary for acceptance into the program.)

Yes

No

Please explain why not.

Please upload a copy of your Parent's / Guardian's 1040 tax form.

Do you have an additional 1040 to upload?

Yes

No

1040 #2

Student Signature

Student Electronic Signature (please type your name)