Online Student Application

1. Start Term *: Select One 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. Ursinus 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 Non - Binary Other/Not Specified Transgender
10. Pronouns: Select One he/him/his he/they per/per/pers she/her/hers she/they they/he they/she they/them/theirs ve/ver/vis zie/hir/hirs

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

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 === ADHD === ASD === Autism Spectrum Disorder === General Category === Other === Hearing === Hearing Impairment === Learning Disability === Auditory Processing Disorder Dysgraphia Dyslexia Dysnomia LD - Not Otherwise Specified Learning Disability Learning Disability - Math Learning Disability - Reading Learning Disability - Writing === Medical === Allergic Rhinitis Allergies Allergy - Mold Allergy - Nuts Allergy - Other Asthma Babesiosis Bladder Dysfunction Bowel Dysfunction Celiac Disease Cerebral Palsy Cervical Sprain Chronic Urticaria Crohn's Disease Dermatomyositis Diabetes Dysautonomia Ehlers Danlos Syndrome Fibromyalgia Gastrointestinal Disease Hasimoto's Disease Hyperacusis IBS Immune Deficiency Insomnia Medical Condition - Other Migraines Mobility Impairment Orthopedic Impairments Other Health Impairment PMDD Pompe Disease POTS Pregnancy Sleep Disorder Spastic Diplegia Spina Bifida Ventricular Tachycardia Wheel Chair Only Ambulation === Neurological === Charcot Marie Tooth Disease Concussion Epilepsy Narcolepsy Neurological Disorder NOS Post Concussive Syndrome Tourette Syndrome Traumatic Brain Injury NOS === Psychological === Anxiety Bipolar Disorder Convergence Disorder Depression Dysthymia Mood Disorder OCD Panic Disorder Post Traumatic Stress Disorder (PTSD) Psychological Condition NOS === Speech === Speech Disorder NOS Stuttering === Visual === Visual Impairment
2. Secondary Disability(ies)

   ADHD

   ADHD

   ASD

   Autism Spectrum Disorder

   General Category

   Other

   Hearing

   Hearing Impairment

   Learning Disability

   Auditory Processing Disorder

   Dysgraphia

   Dyslexia

   Dysnomia

   LD - Not Otherwise Specified

   Learning Disability

   Learning Disability - Math

   Learning Disability - Reading

   Learning Disability - Writing

   Medical

   Allergic Rhinitis

   Allergies

   Allergy - Mold

   Allergy - Nuts

   Allergy - Other

   Asthma

   Babesiosis

   Bladder Dysfunction

   Bowel Dysfunction

   Celiac Disease

   Cerebral Palsy

   Cervical Sprain

   Chronic Urticaria

   Crohn's Disease

   Dermatomyositis

   Diabetes

   Dysautonomia

   Ehlers Danlos Syndrome

   Fibromyalgia

   Gastrointestinal Disease

   Hasimoto's Disease

   Hyperacusis

   IBS

   Immune Deficiency

   Insomnia

   Medical Condition - Other

   Migraines

   Mobility Impairment

   Orthopedic Impairments

   Other Health Impairment

   PMDD

   Pompe Disease

   POTS

   Pregnancy

   Sleep Disorder

   Spastic Diplegia

   Spina Bifida

   Ventricular Tachycardia

   Wheel Chair Only Ambulation

   Neurological

   Charcot Marie Tooth Disease

   Concussion

   Epilepsy

   Narcolepsy

   Neurological Disorder NOS

   Post Concussive Syndrome

   Tourette Syndrome

   Traumatic Brain Injury NOS

   Psychological

   Anxiety

   Bipolar Disorder

   Convergence Disorder

   Depression

   Dysthymia

   Mood Disorder

   OCD

   Panic Disorder

   Post Traumatic Stress Disorder (PTSD)

   Psychological Condition NOS

   Speech

   Speech Disorder NOS

   Stuttering

   Visual

   Visual Impairment
3. Other Disability or Note:

Affiliation(s)

4. Affiliation(s)

   ADD ITEMS IN WEBSITE CONTROL

   SAMPLE - Student Athlete

   SAMPLE - Study Abroad Accommodations

   SAMPLE - TRiO

   SAMPLE - Veteran

Ethnicity(ies)

5. 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
6. Additional Note: