Special Population Survey
REQUIRED TO BE COMPLETED BY ALL NEW CREDIT STUDENTS AND SUBMITTED TO THE OFFICE OF STUDENT AFFAIRS SPECIAL POPULATIONS COORDINATOR
Please provide your name, SSN or Student I.D. number and fill out the section below.
Student I.D. Number
*
Click on the line and type your Student I.D. Number
Full Name
*
First Name
Middle Name
Last Name
Suffix
E-mail
Please provide a valid email address that you check on a daily basis.
Check all that apply to you:
*
I am a student with a documented disability - do you have a physical or mental impairment which substantially limits one or more major life activities such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, or learning?
I am an English learner - do you have a language other than English as your primary language and do you have a limited ability to write or understand English?
I am a person who has the primary or joint custody for a dependent child? You may be divorced, widowed, legally separated, never married or a person who is single and pregnant.
I am a person who is out-of-workforce due to layoffs, relocation of company, or downsizing.
I am an individual who is currently experiencing homelessness.
I am a youth who is in, or has aged out of, the foster care system.
I am a child of a parent who is a member of the armed forces and on active duty.
I am enrolling in a program of study that will lead to an occupation that predominantly employs 25% or less of my gender (i.e. male in nursing, female in welding).
I am from an economically disadvantaged family or a low-income youth or adult (i.e. I receive SNAP or am eligible for Federal Pell Grant).
I choose not to disclose this information.
None of the above apply to me.
I am working toward a:
*
Certificate
Diploma
Degree
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit
Should be Empty: