TRiO SSS Referral Form

Faculty/Staff Referral Form

for

TRiO Student Support Services (SSS)

Instructions:

Thank you for referring a student to the TRiO Student Support Services (SSS) at Worcester State University (WSU) program! We appreciate all referrals as the TRiO SSS program is here to provide additional supports to our students.

Important:

Once you begin, you cannot save and restart this application. Please review the questions and gather any information before you begin. If you have any questions or need additional assistance, please contact our office at (508) 929-8014.

Date: *

Referring Faculty/Staff Member Contact Information:

Full Name: *

WSU Email: *

Best Contact Number: *

Relationship to student: *

Student Contact Information:

Student Name: *

Student School ID *

Student Cell Phone Number: *

Student WSU Email: *

Student Eligibility:

Does this student meet any of the following criteria: *

Provide any additional information that may be relevant in further assisting the student: (4,000 character limit) *

Referring Signature: *

Please select a signature verification type.

Terms of submission:

By submitting this application, you acknowledge that the data provided will only be seen and used by TRiO Student Support Services (SSS) staff to assist in assessing any academic and/or career planning needs and that all of the information will be used in the strictest confidence.

You also understand that TRiO SSS staff will use this information to verify eligibility for participation in the program and does not guarantee acceptance into the program.