Online Student Application

1. Start Term *: Select One 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.
2. 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.
3. 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.
4. First Name *:
5. Last Name *:
6. Middle Name:
7. Optional: Preferred Name:
8. MEID:
   Hint: Enter 10 alpha numeric characters.
9. Birth Date:
   Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
10. Gender *: Select One Female Male Not Specified Other Transgender
11. Pronouns: Select One He/Him Other Prefer Not To Share She/Her They/Them

1. Primary Phone Number:
   Hint: Enter 10-digit number only.
2. Secondary Phone Number:
   Hint: Enter 10-digit number only.
3. Email Address *:

1. Address *:
2. City *:
3. 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
4. Zipcode *:
   Hint: Enter zipcode as 97331 or 97331-0000.

Same as Local Address

1. Address:
2. City:
3. 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
4. Zipcode:
   Hint: Enter zipcode as 97331 or 97331-0000.

1. 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
2. Other Disability or Note:
3. Seeking Degree: Select One Certificate Seeking Degree Seeking Non-Degree Seeking Undecided
4. Major: Select One Applied Technology Behavioral Science and Human Services Business Entrepreneurialism and Management Computer Information Technology Culture and Society Education Health Sciences STEM Undecided Visual and Performing Arts

Affiliation(s)

5. 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)

6. Ethnicity(ies)

   African-American

   Asian or Pacific Islander

   Caucasian

   European-American

   Hispanic

   Multi-Racial

   Native American

   Other

Campus Location(s)

7. 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
8. Additional Note: