SARC Student Intake

Please let us know more about your needs and how we may help you be successful this academic year

First Name*

Last Name*

STUDENT ID (A#)*

Please enter your Student Number after the A

What is your date of birth?*

How did you hear about SARC?*

Select or enter value

CONTACT INFORMATION

Please provide your student email*

Phone*

What's the best way for the Student Advocacy & Resource Center to get in touch with you?*

Select

CAMPUS & ENROLLMENT INFORMATION

Which do you consider your "home" STLCC campus?*

Select

Enrollment Type*

Select all that apply

Select or enter value

BACKGROUND INFORMATION

Please tell us more about your current situation and concerns

Who is currently in your home, or who do you live with?*

Select or enter value

What is the relationship and ages of the children living with you*

Example: sister, age 12 or son, age 5

If you do not have children of your own or live in a home with children (younger siblings, cousins, nieces, nephews, grandchildren, etc.) please type N/A.

What is the relationship of the adults living with you?*

If you live alone please type N/A

Who is financially responsible for the bills/basic needs items at home?*

That is, who is the main person responsible for paying the monthly bills, getting groceries, and other needed items?

Which of the following concern(s) do you currently have?*

Check all that apply

Select or enter value

Please tell us more about your concerns or needs:*

What income and/or support do you currently have?*

Check all that apply

Select or enter value

Employment or Work-Study*

What is your pay-rate and how many hours do you work weekly?

GOALS & CHALLENGES

Future Goals*

Let us know what your goals are for your future

Challenges / Obstacles*

Describe what challenges or obstacles do you have in meeting your goals?

Anything else?

Let us know if there is anything else you would like us to know:

WAIVER

Direct Assistance for food, personal care, clothing, household and cleaning items, school supplies

The Archers' Market, managed by the Student Advocacy & Resource Center, provides donated food and personal care items for students in need. Students utilizing the Archers' Market should understand that none of the parties or groups involved in the center make any warrantees as to the quality of the food or toiletries or their value for any particular purpose. Some of the items distributed by the Archers' Market may have surpassed the manufacturer’s "best buy" consumption date. This date identifies guidance for peak flavor and quality and is not a safety date. Students utilizing the Archers’ Market accept any items "as is." Students completing this waiver through their electronic signature below release the Archers' Market, the Student Advocacy & Resource Center, St. Louis Community College, and any original donor (the "released parties”) from any liability for harm (including injury or death) or losses in connection with the food or supplies received. The student assumes any risks and agrees not to sue the released parties with respect to such harm or losses.

Students using the Archers’ Markets agree to the following:

I understand that the Archers’ Market operates based partially on donations and is an optional service of St. Louis Community College.
I understand that these services are open to me as a currently enrolled St. Louis Community College student.
I agree not abuse the services of the Archers’ Market.
I will only request and take the items that I reasonably expect myself and/or my family to need and use.
I understand that the goal of the Archers’ Market is to help me resolve my immediate need while developing long-term solutions; and the number of visits I make to the Archers’ Market may be limited.
I understand that the privilege of using the Archers’ Market may be denied to me at any time for violation of Student Advocacy & Resource Center or St. Louis Community College policies.

I have read and understand the above information*

I have read an understand the above information

PRIVACY

When working with SARC staff, it is important for students to understand that any information shared with our staff does not fall under the same confidentiality laws as that of a licensed mental health professional. In most cases the communications students have with SARC staff is governed by the Family Educational Rights and Privacy Act (FERPA). This means information will be considered private and can be shared with college officials who have a “legitimate need to know.” SARC staff may consult with other SARC staff, Care Team members, STLCC counselors, or other student affairs professionals and support staff when necessary. When this occurs, consultation only includes disclosure of information essential to meeting student needs. In certain other exceptions, SARC staff may need to share information with other agencies, such as if we become aware of issues of abuse or neglect or if a student discloses they are at risk for hurting themselves or others. Private information shared with the SARC staff will not leave the center except in an emergency. All records and individual documents shared with SARC are kept secured.

CONFIDENTIALITY

When serving as advocates for students experiencing domestic or relationship violence, sexual assault, sexual harassment, stalking, and/or any areas listed in the College’s Nondiscrimination Statement, disclosures to the SARC Coordinators will be kept in strict confidence.

NOTE: Communications with other SARC staff will be considered private, not confidential.

Agreement*

I have read and understand the above information. I give my voluntary consent to participate in the services of the Student Advocacy & Resource Center (SARC).

I agree

I do not agree

Navigate*

The SARC Office can be listed as part of my Success Team in Navigate.

I agree

I do not agree

Send me a copy of my responses

Privacy Notice|Report Abuse