ACE Program Self-Referral Form | Governors State University

Name:

Student ID:

Email:

Phone:

Preferred Contact Method (Email or Phone):

Preferred Pronouns (optional):

Have you been in any of the following situations before the age of 18? (Select all that apply)

At what age did you leave foster care or alternative care arrangement (if applicable)?

What type of support are you hoping to receive while in college? (Select all that apply)

Name:
Student ID:
Email:
Phone:
Preferred Contact Method (Email or Phone):
Preferred Pronouns (optional):
Have you been in any of the following situations before the age of 18? (Select all that apply)	Foster care Kinship care (living with a relative who is not your parent Group home or residential care Legal guardianship with a non-parent Independent living without a parent or guardian None of the above
At what age did you leave foster care or alternative care arrangement (if applicable)?	Still in care Under age 18 Age 18 or older (aged out) Not applicable
What type of support are you hoping to receive while in college? (Select all that apply)	Help with housing (on or off campus) Academic support (tutoring, study skills) Financial assistance or help navigating scholarships/grants Emotional or mental health support Connection with other students from similar backgrounds Life skills or transition support (budgeting, cooking, time management, etc.) Support with employment or career planning Other (please describe):