Thank you for your interest in the Horizons Student Support Services program! Please complete this application as thoroughly as possible. You cannot save and restart this application. You may want to review the requested information, take some time to gather the required documents, and then return to submit your application. If you have any questions, please call our office at 765-494-7094 or email us at horizons@purdue.edu.

Today's Date: *

General Demographic Information:

PUID: *

Purdue Email Address: *

Last Name: *

First Name: *

Middle Name: *

Preferred Name (if not your first name): *

Date of Birth: *

Gender assigned at birth: *

Horizons is inclusive of all students. If you identify differently than your assigned sex at birth, and if you would like us to know, please share your gender identity:

What are your pronouns? *

Permanent Address: *

Permanent Address 2: *

City: *

State: *

Zip: *

Cell Phone: *

Please check the box if we may text this number

Please indicate your racial/ethnic background below. (Please answer Yes or No to each option)

Race, American Indian or Alaskan Native *

Race, Asian: *

Race, Black or African American: *

Race, Hawaiian or other Native to Pacific Island: *

Race, Hispanic: *

Race, White: *

Citizenship Status: *

Program Eligibility:

First Generation Status:

Highest Education Level of Mother or Legal Guardian #1: *

Highest Education Level of Father or Legal Guardian #2: *

With whom did you most often reside with until your 18th birthday? *

Income Information:

Financial Aid Dependency Status: *

Did you or your parent(s)/guardian(s) complete an Income Tax Return for the 2021 reporting year? *

Disability Verification:

Do you have a documented physical, psychological, or learning disability? *

Are you registered with the Purdue University Disability Resource Center (DRC)? *

Additional Information:

Are you a foster child or have you aged out of the foster care system? *

Have you ever been homeless? *

Are you a member of the U.S. Armed Forces? *

Are you a member of the U.S. Reserves? *

Personal Education Information:

Please indicate your previous participation in other TRIO programs. (Check all that apply)

Talent Search

Upward Bound

Educational Opportunity Center

Student Support Services

Academic Status:

What is your current classification according to credit hours earned? *

Are you a transfer student? *

Academic Need Information (Check all that apply to you):

ACT composite score or any subtest (Math, Reading, Science, Social Science) score of 20 or below

SAT Verbal score of 460 or below

SAT Math score of 460 or below

High School GPA Below 3.0

STEAM Major (Science, Technology, Engineering, Agriculture, Math) Pre-Med, or Nursing

College Cumulative GPA between 2.0 - 2.5

Failing grades in one or more courses

Returning adult student (out of the academic pipeline for 5+ years)

In 150 words or less, please let us know what challenges you anticipate facing that could impact your ability to graduate, and how Horizons can best support you. *

Sign and Submit:

I attest that the information I have provided on this application is, to the best of my knowledge, complete and correct. Furthermore, I understand that by applying to the Horizons Student Support Services program, I authorize Horizons program staff to use my Purdue University ID number to obtain records or data pertinent to my participation from other sources. I authorize the release of information, as required by the terms of the TRIO SSS grant, to the grant-funding agency of the United States government. The Horizons program staff have my permission to communicate verbally or otherwise with staff, faculty, and/or off-campus professionals on my behalf.

I am aware that the personal information provided by the Horizons Student Support Services program will be protected under the Family Education Rights Privacy Act of 1974. No one will have access to my information unless they work with or for the Horizons program or are specifically authorized to see information. I understand that any incorrect information on this application may affect my eligibility to receive services from the Horizons Student Support Services program. I give my permission to use my likeness for promotional, recruitment and educational purposes.

Applicant Signature: *

Please select a signature verification type.