Online Student Application

1. Start Term *: Select One 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Spring 2035 - Summer 2035 - Fall 2036 - Spring 2036 - Summer 2036 - Fall 2037 - Spring 2037 - Summer 2037 - Fall 2038 - Spring 2038 - Summer 2038 - Fall 2039 - Spring 2039 - Summer 2039 - Fall 2040 - Spring 2040 - Summer 2040 - Fall 2041 - Spring 2041 - Summer 2041 - Fall 2042 - Spring 2042 - Summer 2042 - Fall 2043 - Spring 2043 - Summer 2043 - Fall 2044 - Spring 2044 - Summer 2044 - Fall 2045 - Spring 2045 - Summer 2045 - Fall 2046 - Spring 2046 - Summer 2046 - Fall 2047 - Spring 2047 - Summer 2047 - Fall 2048 - Spring 2048 - Summer 2048 - Fall 2049 - Spring 2049 - Summer 2049 - Fall 2050 - Spring 2050 - Summer 2050 - Fall
   Note: Select when you would like to start your services.
2. Expected Graduation Term: Select One 2015 - Spring 2015 - Summer 2015 - Fall 2016 - Spring 2016 - Summer 2016 - Fall 2017 - Spring 2017 - Summer 2017 - Fall 2018 - Spring 2018 - Summer 2018 - Fall 2019 - Spring 2019 - Summer 2019 - Fall 2020 - Spring 2020 - Summer 2020 - Fall 2021 - Spring 2021 - Summer 2021 - Fall 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Spring 2035 - Summer 2035 - Fall 2036 - Spring 2036 - Summer 2036 - Fall 2037 - Spring 2037 - Summer 2037 - Fall 2038 - Spring 2038 - Summer 2038 - Fall 2039 - Spring 2039 - Summer 2039 - Fall 2040 - Spring 2040 - Summer 2040 - Fall 2041 - Spring 2041 - Summer 2041 - Fall 2042 - Spring 2042 - Summer 2042 - Fall 2043 - Spring 2043 - Summer 2043 - Fall 2044 - Spring 2044 - Summer 2044 - Fall 2045 - Spring 2045 - Summer 2045 - Fall 2046 - Spring 2046 - Summer 2046 - Fall 2047 - Spring 2047 - Summer 2047 - Fall 2048 - Spring 2048 - Summer 2048 - Fall 2049 - Spring 2049 - Summer 2049 - Fall 2050 - Spring 2050 - Summer 2050 - Fall
   Note: Select when you plan to graduate.
3. First Name *:
4. Last Name *:
5. Middle Name:
6. Optional: Preferred Name:
7. Student ID:
   Hint: Enter 7 alpha numeric characters.
8. Birth Date:
   Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
9. Gender *: Select One Female Male Other/Not Specified Transgender
10. Pronouns: Select One he, him, his she, her, hers they, them, theirs zee, hir, hirs

1. Primary Phone Number:
   Hint: Enter 10-digit number only.
2. Secondary Phone Number:
   Hint: Enter 10-digit number only.
3. Email Address *:

1. Address *:
2. City *:
3. State *: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode *:
   Hint: Enter zipcode as 97331 or 97331-0000.

Same as Local Address

1. Address:
2. City:
3. State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode:
   Hint: Enter zipcode as 97331 or 97331-0000.

1. Primary Disability *: Select One === ADHD/ADD === ADD/ADHD === Autism Spectrum Disorders (ASD) === Autism Spectrum Disorders (ASD) === Learning Disability === COG- Cognitive Learning Disability === Medical === Medical (General conditions) Medical (Temporary Condition) OR- Orthopedic TBI-MED === Psychological Condition === Anxiety Disorders AOD Depression Disorders EMO- Emotional Other Psychiatric Conditions PTSD TBI-PSY === Sensory Conditions === Deaf / Hard of Hearing Sensory- Other Speech Impairment Vision - Blindness Vision - Low Vision and all others === Unknown === Other
2. Secondary Disability(ies)

   ADHD/ADD

   ADD/ADHD

   Autism Spectrum Disorders (ASD)

   Autism Spectrum Disorders (ASD)

   Learning Disability

   COG- Cognitive

   Learning Disability

   Medical

   Medical (General conditions)

   Medical (Temporary Condition)

   OR- Orthopedic

   TBI-MED

   Psychological Condition

   Anxiety Disorders

   AOD

   Depression Disorders

   EMO- Emotional

   Other Psychiatric Conditions

   PTSD

   TBI-PSY

   Sensory Conditions

   Deaf / Hard of Hearing

   Sensory- Other

   Speech Impairment

   Vision - Blindness

   Vision - Low Vision and all others

   Unknown

   Other
3. Other Disability or Note:
4. Seeking Degree: Select One Associates Degree Bachelors Degree Certificate Health Sciences Degree Short term Certificate

Affiliation(s)

5. Affiliation(s)

   African American Male Initiative-AAMI

   CCP- College Credit Plus

   Department of Disability Services (County Services)

   International Student Services

   Military Family Education Center- MFEC

   Opportunities for Ohioans with Disability- OOD

   Student Support Services-TRiO

   Tartan TOPS

Ethnicity(ies)

6. Ethnicity(ies)

   American Indian or Alaska Native

   Asian

   Black or African American

   Hispanic or Latino

   Native Hawaiian or Other Pacific Islander

   Other/Not Reported

   White

Campus Location(s)

7. Campus Location(s)

   Centerville

   Dayton

   Mason

   Online
8. Additional Note:

1. Which Status best applies to you?

   College Credit Plus (CCP)

   First Semester

   Referred by Faculty

   Referred by Academic Advisor or Student Services

   Referred due to SAP or Medical Withdraw process

   Other

   Additional Note or Comment
2. Identify and describe your disability/disabilities (including when diagnosed and how identified.)
3. If applicable, identify medications you are currently taking and how they impact you.
4. If you received accommodations in high school or while taking college courses, what do you feel worked well?
5. What accommodations are you seeking while at Sinclair?