DSS: Online Application

Personal Information First Name: Middle Initial: Last Name: Birthdate: Student Number: Gender Male Female E-mail: Ethnic Background Asian American/Asian American Indian/Alaskan Native African American/African Caucasian Hispanic Multinational Decline to Answer
	Permanent Address Information Street: City: State: Zip Code: Telephone #: Local Address Information Same as permanent address. (if different from permanent address) Street: City: State: Zip Code: Telephone #:
Disability Information Do you have a disability? Yes No If Yes, please describe: Are you taking any prescribed medication (disability related)? Yes No If Yes, please specify: Are you associated with any rehabilitation services (i.e. MI Rehab or MI Commission for the blind)? Yes No If Yes, please specify: How did you learn about DSS? Education and Career Goals Are you currently enrolled at GVSU? Yes No If No, what semester and year do you plan to attend? Fall Winter Summer Year Current Class Standing: Freshman Sophomore Junior Senior GraduateStudent Will you be receiving financial aid (grants, loans, and/or scholarships)? Yes No Intended Major: Career Goal: College(s) previously attended: Employment/Time Constraints Are you employed? Yes No If Yes, how many hours per week?