Accessible Education Application

First name:

Middle Name:

Last Name:

StudentID#:

Mailing Address:

City:

State:

Zip Code:

Email Address:

Preferred contact phone#:

Date of Birth:

Gender:

Ethnicity:

Race:

US Citizen?

US Veteran?

Do either parents have a BA or BS Degree?

Are you currently receiving college financial aid?

How are you financing your education?

Did you graduate from High School?

If you did not graduate High School, do you have:

Are you enrolled, or plan to be enrolled, at SWOCC:

Program:

Academic Advisor:

Do you plan to transfer to get a four-year degree?

Names of colleges you are interested in attending after graduation or transfer from SWOCC:

College 1:

College 2:

Disability/Diagnosis:

If Other, describe here:

List reasonable academic accommodations reviewed in the past:

How did you learn about the Access Education Office?

If Other, describe here:

This application is filled out to the best of my knowledge.  I understand that information I share with the Access Education Office (AEO) staff will be kept strictly confidential according to the rules and policies of the college.  I also understand that information from all other offices at Southwestern Oregon Community College can be requested to complete my AEO file.

Southwestern Oregon Community College
Student Success Center
Accessible Education Office
541-888-7405