Thank you for your interest in our 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 included items, take some time to make notes and gather the required documents, and then return to submit your application.  If you have any questions, please call our office at (517) 265-5161 x: 4094 or email Academic Services (

General Information:
Last Name: *
First Name: *
Middle Name:
Date of Birth: *
Describe your primary reason for applying: *
Address: *
Address 2:
City: *
State: *
Zip Code: *
Cell Phone Number: *
Email Address:

Family Information:
Highest Level of Education Attained by either Parent or Legal Guardian: *
How many people in your household at home? (Include yourself.)
Family Income Range:
A parent/guardian's signature is required for this portion of the application.  We get those signatures by sending an electronic document to there email address and they sign and it sends back to us electronically.  Please make sure the email address is correct and tell your parent/guardian to be on the lookout for an email from HelloSign.  You will be emailed at your Adrian email address when the electronic document has been sent to the parent/guardian. If you believe you are an independent student, please contact our office at 517-264-4093.
Parent/Guardian First and Last Name *
Parent/Guardian Email Address *

Sign and Submit:
Applicant Signature *
Please select a signature verification type.
Terms of Submission:
By submitting this application, you acknowledge that all of the above information is correct and accurate to the best of your understanding.