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 (required)

Contact Name (required)

Contact Telephone (required)

Address (required)

Contact Email (required)

How would you like us to contact you? (required)

Do you currently have services through any of the following state agencies/programs? (required)
Yes: NOW/COMP Waiver ServicesYes: Vocational RehabilitationNo

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

Type of disability (may select multiple) (required)
BlindDeafIntellectualOther Physical

Please indicate legal guardianship status
Own GuardianParent is Legal GuardianOther Guardianship