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