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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.
Expected Graduation Term:
Select One
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.
First Name
*
:
Last Name
*
:
Middle Name:
Optional: Preferred Name:
Student ID
*
:
Hint: Enter 9 alpha numeric characters.
Birth Date:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Gender
*
:
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Another
Female
Male
Other/Not Specified
Unknown
Pronouns:
Select One
he, him, his, his, himself
per, per, pers, pers, perself
she, her, her, hers, herself
they, them, their, theirs, themself
ve, ver, vis, vers, verself
zie, hir, hir, hirs, hirself
Contact Information
Primary Phone Number:
Hint: Enter 10-digit number only.
Secondary Phone Number:
Hint: Enter 10-digit number only.
Email Address
*
:
Local Address
Address:
City:
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
Zipcode:
Hint: Enter zipcode as 97331 or 97331-0000.
Permanent Address
Same as Local Address
Address:
City:
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
Zipcode:
Hint: Enter zipcode as 97331 or 97331-0000.
Additional Information
Campus Location(s)
Campus Location(s)
BACHE
Consortium
Hybrid
Jefferson State CC Campus
Main
Off Campus
Online
Regional Service Center Pelham
Study Away
Additional Note:
Questions
What is your current university classification?
*
(Selection is Required)
Incoming Freshman
Freshman
Sophomore
Junior
Senior
Graduate
Dual Enrollment
Non-degree seeking
Additional Note or Comment
Are you or will you be a member of a UM athletic team? If so, please state which sport.
*
(Selection is Required)
Yes (Specify Below)
No
Additional Note or Comment
Please list an emergency contact person (name, phone number, and relationship).
What is your military status?
*
(Selection is Required)
Active
Reserve
Retired
Disabled Veteran
Military Dependent
None of the Above
Additional Note or Comment
How did you hear about our office?
Academic Advisor
Family Member
Instructor
Counseling Center
Student Health Center
Other (Specify Below)
Additional Note or Comment
Are you living on campus now or will you be living on campus after enrollment?
*
(Selection is Required)
Yes
No
Additional Note or Comment
Does your disability impact you in educational environments?
*
(Selection is Required)
Yes (Specify Below)
No
Additional Note or Comment
Please indicate the general area(s) of your disability or diagnosis. Check all that apply. Please provide specific diagnosis below.
Medical/Health (Specify Below)
Orthopedic/Mobility (Specify Below)
Blindness/Low Vision (Specify Below)
Deaf/Hard of Hearing (Specify Below)
Autism Spectrum Disorder (Specify Below)
Traumatic Brain Injury/Post-Concussive Syndrome (Specify Below)
Mental Health (Specify Below)
Additional Note or Comment
Please list relevant prescription medications and/or any medication related side effects that impact your functioning in housing or the educational environment.
What Specific Housing Accommodations have you previously been approved for?
Single Room
Room on First Floor/Limited Stairs (Specify Below)
Accessible Room/Wheelchair Access
Accessible Height Desk/Table for Equipment
More Than One Desk/Table for Equipment
Use of Hospital Bed
Need For Personal Care Attendant
Emotional Support Animal
Use of Service Animal
Medical Private Kitchen
Close Proximity to Kitchen
Modified Meal Plan/Meal Plan Waiver
Flashing Strobe Fire Alarm
Medical Private Bathroom
Shower/Bathroom Grab Bars
Handheld/Adjustable Shower Head
Roll in Shower
Semi Private-non communal bathroom
Close Proximity to Community Bathroom
Other (Specify Below)
Additional Note or Comment
Please detail the necessary/requested Housing or non-Academic Accommodations you are requesting below:
Private Room
Room on First Floor/Limited Stairs (Specify Below)
Access to First Floor Laundry (Specify Below)
Accessible Room/Wheelchair Access
Accessible Height Desk/Table for Equipment
More Than One Desk/Table for Equipment
Use of Hospital Bed
Need for Personal Care Attendant
Emotional Support Animal
Use of Service Animal
Use of a Service Dog in Training
Medical Private Kitchen
Close Proximity to Kitchen
Modified Meal Plan
Meal Plan Waiver
Flashing Strobe Fire Alarm
Medical Private Bathroom
Shower/Bathroom Grab Bars
Handheld/Adjustable Shower Head
Semi Private Non-Communal Bathroom
Alarm (Specify Below)
Other (Specify Below)
Additional Note or Comment
Does your disability or medical condition create dietary or meal plan restrictions. If so, please describe below.
*
(Selection is Required)
Yes (Specify Below)
No
Additional Note or Comment
Do you require assistive technology or equipment (magnification, assistive listening device, laptop, etc.)? If so, please describe below
*
(Selection is Required)
Yes (Specify Below)
No
Additional Note or Comment
What Specific Housing Accommodations would you like to discuss during your intake?
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