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Online Student Application
Online Student Application
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I certify that the information recorded on this application is correct, and hereby give my permission to communicate, on a need to know basis, with any MCCCD Department and instructors who will benefit my academic progress for the duration of my education at Maricopa County Community College District (MCCCD).
Please be advised that MCCCD Disability Resources and Services offices (DRS) retain student documentation and disability files in accordance with record retention policies. Please keep your original documentation and make a separate copy for our office. The DRS office cannot return documentation to students.
Please check the email you provided on this application for application status.
Personal Information
Start Term
*
:
Select One
2023 - Summer
2023 - Fall
2023 - Clock
2024 - Spring
2024 - Summer
2024 - Fall
2024 - Clock
2025 - Spring
2025 - Summer
2025 - Fall
2025 - Clock
2026 - Spring
2026 - Summer
2026 - Fall
2026 - Clock
2027 - Spring
2027 - Summer
2027 - Fall
2027 - Clock
2028 - Spring
2028 - Summer
2028 - Fall
2028 - Clock
2029 - Spring
2029 - Summer
2029 - Fall
2029 - Clock
2030 - Spring
2030 - Summer
2030 - Fall
2030 - Clock
2031 - Spring
2031 - Summer
2031 - Fall
2031 - Clock
2032 - Spring
2032 - Summer
2032 - Fall
2032 - Clock
2033 - Spring
2033 - Summer
2033 - Fall
2033 - Clock
2034 - Spring
2034 - Summer
2034 - Fall
2034 - Clock
2035 - Spring
2035 - Summer
2035 - Fall
2035 - Clock
2036 - Spring
2036 - Summer
2036 - Fall
2036 - Clock
2037 - Spring
2037 - Summer
2037 - Fall
2037 - Clock
2038 - Spring
2038 - Summer
2038 - Fall
2038 - Clock
2039 - Spring
2039 - Summer
2039 - Fall
2039 - Clock
2040 - Spring
2040 - Summer
2040 - Fall
2040 - Clock
2041 - Clock
2042 - Clock
2043 - Clock
2044 - Clock
2045 - Clock
2046 - Clock
2047 - Clock
2048 - Clock
2049 - Clock
2050 - Clock
Note: Select when you would like to start your services.
Primary Campus
*
:
Select One
CGCC Chandler-Gilbert Pecos
CGCC Communiversity at Queen Creek
CGCC Williams
EMCC Estrella Mountain
GCC Glendale
GCC Glendale North Campus
GWCC Gateway Central City
GWCC Gateway Deer Valley
GWCC Gateway Washington
GWCC Southwest Skills Center
GWCC Surprise
MCC Mesa Southern and Dobson
MCC Red Mountain
PC Phoenix College
PVCC Paradise Valley
PVCC Paradise Valley Black Mountain
RSC RIO HSE
RSC RIO National
RSC RIO Tempe
SCC Scottsdale
SMCC South Mountain
Note: Please select campus location where you will be enrolled.
Expected Graduation Term:
Select One
2010 - Spring
2010 - Summer
2010 - Fall
2011 - Spring
2011 - Summer
2011 - Fall
2012 - Spring
2012 - Summer
2012 - Fall
2013 - Spring
2013 - Summer
2013 - Fall
2014 - Spring
2014 - Summer
2014 - Fall
2015 - Spring
2015 - Summer
2015 - Fall
2016 - Spring
2016 - Summer
2016 - Fall
2016 - Clock
2017 - Spring
2017 - Summer
2017 - Fall
2017 - Clock
2018 - Spring
2018 - Summer
2018 - Fall
2018 - Clock
2019 - Spring
2019 - Summer
2019 - Fall
2019 - Clock
2020 - Spring
2020 - Summer
2020 - Fall
2020 - Clock
2021 - Spring
2021 - Summer
2021 - Fall
2021 - Clock
2022 - Spring
2022 - Summer
2022 - Fall
2022 - Clock
2023 - Spring
2023 - Summer
2023 - Fall
2023 - Clock
2024 - Spring
2024 - Summer
2024 - Fall
2024 - Clock
2025 - Spring
2025 - Summer
2025 - Fall
2025 - Clock
2026 - Spring
2026 - Summer
2026 - Fall
2026 - Clock
2027 - Spring
2027 - Summer
2027 - Fall
2027 - Clock
2028 - Spring
2028 - Summer
2028 - Fall
2028 - Clock
2029 - Spring
2029 - Summer
2029 - Fall
2029 - Clock
2030 - Spring
2030 - Summer
2030 - Fall
2030 - Clock
2031 - Spring
2031 - Summer
2031 - Fall
2031 - Clock
2032 - Spring
2032 - Summer
2032 - Fall
2032 - Clock
2033 - Spring
2033 - Summer
2033 - Fall
2033 - Clock
2034 - Spring
2034 - Summer
2034 - Fall
2034 - Clock
2035 - Spring
2035 - Summer
2035 - Fall
2035 - Clock
2036 - Spring
2036 - Summer
2036 - Fall
2036 - Clock
2037 - Spring
2037 - Summer
2037 - Fall
2037 - Clock
2038 - Spring
2038 - Summer
2038 - Fall
2038 - Clock
2039 - Spring
2039 - Summer
2039 - Fall
2039 - Clock
2040 - Spring
2040 - Summer
2040 - Fall
2040 - Clock
2041 - Clock
2042 - Clock
2043 - Clock
2044 - Clock
2045 - Clock
2046 - Clock
2047 - Clock
2048 - Clock
2049 - Clock
2050 - Clock
Note: Select when you plan to graduate.
First Name
*
:
Last Name
*
:
Middle Name:
Optional: Preferred Name:
MEID:
Hint: Enter 10 alpha numeric characters.
Birth Date:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Gender
*
:
Select One
Female
Male
Not Specified
Other
Transgender
Pronouns:
Select One
He/Him
Other
Prefer Not To Share
She/Her
They/Them
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
Primary Disability
*
:
Select One
=== Acquired Brain Injury ===
Stroke
TBI
=== ADD / ADHD ===
ADD
ADHD
=== Autism Spectrum Disorders ===
Asperger's
Autism
PDD
PDD NOS
=== Blind ===
Blind
=== Deaf ===
Deaf
Single-sided Deafness
Usher's Syndrome
=== Deaf-Blind ===
Complete Hearing Loss
Complete Vision Loss
Deaf-Blind
Partial Hearing Loss
Partial Vision Loss
=== General Category ===
Other
=== Hard of Hearing ===
Acoustic Neuroma
Hard of Hearing
Meniere's Disease
=== Intellectual ===
Borderline Intellectual Functioning
Developmentally Delayed (DD)
Mild Mentally Impaired (MMI)
Mild Mentally Impaired NOS
=== Learning Disability ===
Auditory Processing
Communication
Dyslexia
Non-Verbal Learning Disability
Specific Learning Disability - all categories
Specific Learning Disability - READING
Specific Learning Disability - WRITING
Specific Learning Disabilty - MATH
Speech Language Impairment (SLI)
=== Neurological ===
Brain Surgery/Tumor
Cerebral Palsy
Chronic Insomnia
Chronic Migraines
Cubital Tunnel Syndrome
Epilepsy
Fibromyalgia
Multiple Sclerosis (MS)
Narcolepsy
Neurological Issues - general
Seizure Disorder
Tourette's Syndrome
=== Not Diagnosed / Unknown ===
Unknown
Waiting on results
=== Other ===
Down Syndrome
Other Health Impairment
Trisomy X Syndrome
=== Physical ===
Arthritis
Carpal Tunnel Syndrome
Chronic Pain
Physical General
Quad/Paraplegic
Somatoform Disorders - non-physical body pain or symptoms
=== Pregnant and Parenting Services ===
Pregnancy Complications
=== Psychiatric ===
Agoraphobia
Anxiety Disorder
Bipolar Disorder
Depression
Drug Addiction - not currently using
Dysthymia - mild but long term form of depression
Memory Loss
Mood Disorders
Obsessive Compulsive Disorder (OCD)
Panic Attacks
Psychiatric General
PTSD
Schizoaffective Disorder
Schizophrenia
=== Systemic ===
Cancer
Cardiovascular System
Digestive System
Endocrine System
Heart disease
Hematological Disorders
Immune System Disorders
Malignant Neoplastic Disease
Respiratory System
Skin Disorders
=== Temporary ===
Temporary - General
=== Visually Impaired ===
Low Vision
Macular Degeneration
Retinitis Pigmentosa
Vision Loss
Other Disability or Note:
Seeking Degree:
Select One
Certificate Seeking
Degree Seeking
Non-Degree Seeking
Undecided
Major:
Select One
N/A
Affiliation(s)
Affiliation(s)
ACE
Athletes
Booster Club
Distance Education
Dual Enrollment Student
EOP/SSS
EXCEL
First Place
Foster Care
Foundation for Blind Children (FBC)
GateWay Early College High School
Honors
HSE Program
International Students
LIFT
NorthBridge Applicant - application on file
NorthBridge College Success Program
One Step Beyond
PCPA
Phi Theta Kappa
SAAVI Services for the Blind
Student Club
Tangram
TRIO
Veterans
Vocational Rehabilitation (VR)
WESTMEC
Year-up program
Youth Build Program
Youth Transition Program
Ethnicity(ies)
Ethnicity(ies)
African-American
Asian or Pacific Islander
Caucasian
European-American
Hispanic
Multi-Racial
Native American
Other
Campus Location(s)
Campus Location(s)
CGCC Chandler-Gilbert Pecos
CGCC Communiversity at Queen Creek
CGCC Williams
EMCC Estrella Mountain
GCC Glendale
GCC Glendale North Campus
GWCC Gateway Central City
GWCC Gateway Deer Valley
GWCC Gateway Washington
GWCC Southwest Skills Center
GWCC Surprise
MCC Mesa Southern and Dobson
MCC Red Mountain
PC Phoenix College
PVCC Paradise Valley
PVCC Paradise Valley Black Mountain
RSC RIO HSE
RSC RIO National
RSC RIO Tempe
SCC Scottsdale
SMCC South Mountain
Additional Note:
Questions
Have you ever registered with a Disability Services Office at MCCCD before? If so, please indicate which campus you registered at in the space provided.
*
(Selection is Required)
Yes
No
Additional Note or Comment
Are you a... (check all that apply)
New Student
Returning Student
Transfer Student
High School Graduate
Student who has completed their GED
Additional Note or Comment
If you are a new student to MCCCD, have you attended a New Student Orientation?
*
(Selection is Required)
Yes
No
Registered to Attend
Additional Note or Comment
Are you currently enrolled in any MCCCD courses?
*
(Selection is Required)
Yes
No
Additional Note or Comment
How did you find out about Disability Resources & Services (check all that apply)?
High School Resource Teacher
Friend
College Advisor
Stated in College Syllabus
College Instructor
DRS Signs on campus
Voc Rehab Case Manager
Parent
Other
Additional Note or Comment
Have you had disability accommodations in the past?
*
(Selection is Required)
yes
no
Additional Note or Comment
If you have received accommodations in the past, either here or at another institution, what were they?
*
(Required)
Are there other accommodations (not listed in previous question) you would like to request or have questions about?
*
(Required)
Do you currently have documentation to verify a disability? (Please note: your application will still be processed if you do not upload documentation at this time)
*
(Selection is Required)
Yes, I have documentation to upload.
No, I do not have documentation to upload.
Additional Note or Comment
Do you have any additional questions for the Disability Resources & Services office?
*
(Required)
Please provide a phone number where you can be reached.
*
(Required)
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