The Educational Support Program - Grand Valley State University

Phone: 616-331-3401
Fax: 616-331-2775
Sherri Velderman
frontesp@gvsu.edu

239 Student Services
Allendale, MI 49401

ESP Application

Name:
Email:
Student ID (G#):
Gender:	Male Female
Date of Birth:
Class Standing:
Ethnic Background:

	Local Address		Permanent Address
Address:		Address:

City:		City:
State:		State:
Zip Code:		Zip Code:

Phone

Cell Phone:
Local Phone:
Permanent Phone:

Other Information

Please mark any of the following programs that you've ever been involved with:
TRiO Student Support Services	MICUP
TRiO Educational Talent Search	MOST
TRiO Upward Bound	DSS (OAS)
Excel

Is this your first time in college?
Are you a transfer student?
College/University you are transferring from:
Are or were you an orphan or ward of the court?
Have either of your parents graduated from a 4-year college?
Did you apply for financial aid for this academic year?
Are you a U.S. Citizen, Resident Alien or Permanent Resident?
Do you have children?
How many children do you have?

US Military service (if applicable)

Please check all that apply:

On active military duty
Veteran of U.S. Armed Forces
Reserves or National Guard
I am a dependent or spouse of a U.S. active duty service member

What can ESP help you with?

Please select a minimum of 3:

Academic Counseling	Personal Counseling	Financial Aid Assistance
Scheduling	Career Counseling	Goal Setting
Test Anxiety	Motivation	Intensive Math Support
Other

How did you hear about ESP?

A high school counselor/advisor
A counselor/advisor at another college
A GVSU faculty or staff member outside of ESP
An ESP staff member or mentor
A friend/family member who is a participant
The ESP website
Other:

Please Read Before Signing: (you will sign this form during your first meeting in ESP)

By signing below, I agree that I have read and understand the following:

I understand that my commitment to ESP is for one year, and that I am expected to meet with my advisor at least two times per semester.
I understand that ESP will collect information about my participation in the program for the purposes of developing statistical data, evaluating program efficacy, and assessing my academic and/or career needs
I understand that ESP may use my name and/or picture in promotional materials, including (but not limited to) its monthly newsletter and its website
I understand that information shared with my advisor and/or peer mentor will be kept confidential; furthermore, I understand that such information will not be shared with University faculty/staff members outside of the program without my verbal or written consent, with the following exceptions:

Expressed or suspected risk of harm to self
Expressed or suspected risk or harm to others
Revealed knowledge of the abuse of a minor child

Grand Valley State University is an Equal Opportunity/Affirmative Action Institution