Interest Form

Thank you for your interest in our programs and services!

Please complete this form so can contact you to provide with additional information.

    Which campus are you interested in attending?

    Individual's Name

    Individual's Date of Birth

    Expected Date of High School graduation (if relevant)

    Contact Name (required)

    Contact's Relation to Individual

    Contact Telephone (required)

    Address (required)

    Contact Email (required)

    How should we contact you? (required)
    EmailTelephone

    Do you currently have services through any of the following state agencies/programs? (required)
    NOW/COMP Waiver ServicesVocational RehabilitationState FundedNo

    If applicable, please list the name of your support coordinator or VR Counselor

    Type of disability (may select multiple) (required)
    BlindDeafIntellectualBehavioral HealthOther

    Please indicate legal guardianship status
    Own GuardianParent is Legal GuardianOther Guardianship

    Add any other relevant information here