SDS Interest Form

Columbus Technical College ID Number*

Full Name

First Middle Last Suffix

Full Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

County

Phone

Major

Email

Advisor

Agency Counselor

Untitled

New Student
Returning

Untitled

New Student
Returning

Sex

Male
Female

Date of Birth (example: 1/1/2000)

Educational Level (example: HS)

Untitled

Financial Sponsor (check all that apply)

Pell
Hope
VR
VA/VR (DAV)
WIA
Scholarship
Workers Comp
Paying your own way

Note: if you deny having a disability, Student Disability Services will be unable to assist you. You must list your disability if you require special accommodations.

List your disability (Please be specific)

Do you have professional documentation of your disability?

Yes
No

Other source (please list)

Will you require special accommodations?

Yes
No

What accommodations requested?

With reasonable accommodations or adjustments, will you be able to receive training as dictated by the State standards and directed by the policies and procedures of the institution?

Yes
No

Are you presently taking any doctor-prescribed medication, due to your disability or otherwise?

Yes
No

Will any of the above medication interfere with your ability to reasonably function?

Yes
No

Blind or Visually Impaired Students: How will you prefer your reading materials?

Audio
CD
Braille Level 1
Braille Level 2

If you are selecting the CIS program, have you had any computer literacy training

Yes
No

Contact Person

Relationship to Student

Daytime Telephone

Evening Telephone

Alternate Phone Number

Second Contact Person

Second Contact's Relationship to Student

Daytime Telephone

Alternate Phone Number

Instructor(s)

Administrator(s)

Others

CAPTCHA

SDS Interest Form

Student Disability Services Information Form

Author

Division of Health Sciences and Nursing

News

About

Enrollment Services

Academics

Adult Education

Economic Development

Community

Future Students

Current Students