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Online Student Application

Two easy steps to register
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Welcome to Access and Disability Services, Pierce College. Please complete the form below in it's entirety. This will help us serve you better!

Please know that the information you provide will be kept private in accordance with the Family Education Rights & Privacy Act (FERPA). For more information on FERPA, please visit: http://www.pierce.ctc.edu/ferpa
Personal Information
  1. Note: Select when you would like to start your services.
  2. Note: Select when you plan to graduate.
  7. Hint: Enter 9 alpha numeric characters.
  8. Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Contact Information
  1. Hint: Enter 10-digit number only.
  2. Hint: Enter 10-digit number only.
Local Address
  4. Hint: Enter zipcode as 97331 or 97331-0000.
Permanent Address
  4. Hint: Enter zipcode as 97331 or 97331-0000.
Additional Information
  2. Secondary Disability(ies)

    01 Deaf/Hearing

    02 Mobility

    03 Speech/Language

    04 Learning Disability

    05 Blind/Visual

    06 Chronic/Acute Health

    07 Neurological/Nervous System

    08 Psychological/Emotional

    99 Other

  4. Ethnicity(ies) *
  5. Campus Location(s)

Questions

  2.  
    Have you used accommodations during previous educational/employment experiences?
  3.  
    What accommodations would you like to discuss during your appointment? * (Selection is Required)
  4.  
    Do you have or can you obtain current documentation of your disability (or temporary medical condition)?
  5.  
    If you do not have current documentation, would you like someone from ADS to contact you to talk about options and next steps? Please be aware that not having current documentation does not automatically disqualify you from receiving services through ADS.
  6.  
    Release of Information for during Intake OR any time afterwards until I revoke consent in writing. By checking the consent box, I understand that I am giving permission to Disability and Access Services at Pierce College to discuss the information that I check below with the individual(s) I list in question #7. NOTE: this is for people/organizations OUTSIDE of Pierce College * (Selection is Required)
  7.  
    Check the appropriate box then list the NAME and CONTACT INFORMATION of the people or organization you are consenting to Release your information to in the "Additional Notes or Comments" box below:
  8.  
    Are you receiving educational benefits through any of the following:
  9.  
    (Optional Question) Do you participate in any of the following programs (check all that apply):
  10.  
    How did you learn about ADS? (Check all that apply)
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