Online Student Application

1. Start Term *: Select One 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Winterim 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Winterim 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Winterim 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Winterim 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Winterim 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Winterim 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Winterim 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Winterim 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Winterim 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Winterim 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Winterim 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Winterim 2035 - Spring 2035 - Summer 2035 - Fall 2036 - Winterim 2036 - Spring 2036 - Summer 2036 - Fall 2037 - Winterim 2037 - Spring 2037 - Summer 2037 - Fall 2038 - Winterim 2038 - Spring 2038 - Summer 2038 - Fall 2039 - Winterim 2039 - Spring 2039 - Summer 2039 - Fall 2040 - Winterim 2040 - Spring 2040 - Summer 2040 - Fall 2041 - Winterim 2041 - Spring 2041 - Summer 2041 - Fall 2042 - Winterim 2042 - Spring 2042 - Summer 2042 - Fall 2043 - Winterim 2043 - Spring 2043 - Summer 2043 - Fall 2044 - Winterim 2044 - Spring 2044 - Summer 2044 - Fall 2045 - Winterim 2045 - Spring 2045 - Summer 2045 - Fall 2046 - Winterim 2046 - Spring 2046 - Summer 2046 - Fall 2047 - Winterim 2047 - Spring 2047 - Summer 2047 - Fall 2048 - Winterim 2048 - Spring 2048 - Summer 2048 - Fall 2049 - Winterim 2049 - Spring 2049 - Summer 2049 - Fall 2050 - Winterim 2050 - Spring 2050 - Summer 2050 - Fall
   Note: Select when you would like to start your services.
2. Expected Graduation Term: Select One 2013 - Winterim 2013 - Spring 2013 - Summer 2013 - Fall 2014 - Winterim 2014 - Spring 2014 - Summer 2014 - Fall 2015 - Winterim 2015 - Spring 2015 - Summer 2015 - Fall 2016 - Winterim 2016 - Spring 2016 - Summer 2016 - Fall 2017 - Winterim 2017 - Spring 2017 - Summer 2017 - Fall 2018 - Winterim 2018 - Spring 2018 - Summer 2018 - Fall 2019 - Winterim 2019 - Spring 2019 - Summer 2019 - Fall 2020 - Winterim 2020 - Spring 2020 - Summer 2020 - Fall 2021 - Winterim 2021 - Spring 2021 - Summer 2021 - Fall 2022 - Winterim 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Winterim 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Winterim 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Winterim 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Winterim 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Winterim 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Winterim 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Winterim 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Winterim 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Winterim 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Winterim 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Winterim 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Winterim 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Winterim 2035 - Spring 2035 - Summer 2035 - Fall 2036 - Winterim 2036 - Spring 2036 - Summer 2036 - Fall 2037 - Winterim 2037 - Spring 2037 - Summer 2037 - Fall 2038 - Winterim 2038 - Spring 2038 - Summer 2038 - Fall 2039 - Winterim 2039 - Spring 2039 - Summer 2039 - Fall 2040 - Winterim 2040 - Spring 2040 - Summer 2040 - Fall 2041 - Winterim 2041 - Spring 2041 - Summer 2041 - Fall 2042 - Winterim 2042 - Spring 2042 - Summer 2042 - Fall 2043 - Winterim 2043 - Spring 2043 - Summer 2043 - Fall 2044 - Winterim 2044 - Spring 2044 - Summer 2044 - Fall 2045 - Winterim 2045 - Spring 2045 - Summer 2045 - Fall 2046 - Winterim 2046 - Spring 2046 - Summer 2046 - Fall 2047 - Winterim 2047 - Spring 2047 - Summer 2047 - Fall 2048 - Winterim 2048 - Spring 2048 - Summer 2048 - Fall 2049 - Winterim 2049 - Spring 2049 - Summer 2049 - Fall 2050 - Winterim 2050 - Spring 2050 - Summer 2050 - Fall
   Note: Select when you plan to graduate.
3. First Name *:
4. Last Name *:
5. Middle Name:
6. Optional: Preferred Name:
7. Student ID:
   Hint: Enter 7 alpha numeric characters.
8. Birth Date:
   Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
9. Gender *: Select One Female Male Not Specified
10. Pronouns: Select One he other she they

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 === General Category === Other === Hearing === Bilateral Deafness Deaf Hearing loss Other not listed - Hearing Tinnitus === Medical/Physical/Chronic Health === Adenomyosis Aplastic Anemia Arthritis Asthma Celiac Disease Cerebral Palsy Chronic Migraines Chronic Pain Colitis Concussion Congenital Heart Defect Crohn's Disease Cystic Fibrosis Diabetes Dysautonomia Ehlers-Danlos Syndrome (EDS) Endometriosis Epilepsy Fibromyalgia Food Allergy Gastroparesis/GI Rumination Height Restriction (too tall/too short) Hypertrophic Cardiomyopathy (HCM) Immunocompromised Insomia Irritable Bowel Syndrome (IBS) Lactose Introlerant Leukemia Long Term COVID Lupus Lyme Disease Lymphedema Mixed Connective Tissue Disease (MCTD) Mobility Impairment Multiple Sclerosis Narcolepsy Neuromuscluar disease Neuropathy Other not listed - medical/physical/Chronic Health PCOS Postural Orthostatic Tachycardia Syndrome (POTS) Premenstrual Dysphoric Disorder (PMDD) Reactive Airway Disease Rheumatoid Arthritis Scoliosis Sickle Cell Disease Spherocytosis Spinal Cord Injury Syncope Thalassemia === Neurodevelopmental/Cognitive Disorder === ADHD/ADD Aspergers Auditory Processing Disorder Autism Spectrum Disorder (ASD) Dyscalcuia Dysgraphia Dyslexia Graphomotor Language Processing Disorder Memory Disorder Other not listed - Neurodevelopmental/Cognitive Disorder Pervasive Development Disorder Social Pragmatic Disorder Specific Learning Disability (SLD) Specific Learning Disorder -- Math Specific Learning Disorder -- Reading Visual Processing and Integration Disorder === Psychological === Anorexia-nervosa Anxiety Bipolar Disorder Borderline Personality Disorder Bulimia Nervosa Conduct Disorder Depression Generalized Anxiety Disorder (GAD) Major Depressive Disorder (MDD) Obsessive Compulsive Disorder (OCD) Other not listed - Psychological Panic Disorder Paranoia Posttraumatic Stress Syndrome(PTSD) Schizoaffective Disorder Schizophrenia Tourette Syndrome === Traumatic Brain Injury === Traumatic Brain Injury === Visual === Blind Double Vision Low Vision Other not listed - Visual Vision Impairment
2. Secondary Disability(ies)

   General Category

   Other

   Hearing

   Bilateral Deafness

   Deaf

   Hearing loss

   Other not listed - Hearing

   Tinnitus

   Medical/Physical/Chronic Health

   Adenomyosis

   Aplastic Anemia

   Arthritis

   Asthma

   Celiac Disease

   Cerebral Palsy

   Chronic Migraines

   Chronic Pain

   Colitis

   Concussion

   Congenital Heart Defect

   Crohn's Disease

   Cystic Fibrosis

   Diabetes

   Dysautonomia

   Ehlers-Danlos Syndrome (EDS)

   Endometriosis

   Epilepsy

   Fibromyalgia

   Food Allergy

   Gastroparesis/GI Rumination

   Height Restriction (too tall/too short)

   Hypertrophic Cardiomyopathy (HCM)

   Immunocompromised

   Insomia

   Irritable Bowel Syndrome (IBS)

   Lactose Introlerant

   Leukemia

   Long Term COVID

   Lupus

   Lyme Disease

   Lymphedema

   Mixed Connective Tissue Disease (MCTD)

   Mobility Impairment

   Multiple Sclerosis

   Narcolepsy

   Neuromuscluar disease

   Neuropathy

   Other not listed - medical/physical/Chronic Health

   PCOS

   Postural Orthostatic Tachycardia Syndrome (POTS)

   Premenstrual Dysphoric Disorder (PMDD)

   Reactive Airway Disease

   Rheumatoid Arthritis

   Scoliosis

   Sickle Cell Disease

   Spherocytosis

   Spinal Cord Injury

   Syncope

   Thalassemia

   Neurodevelopmental/Cognitive Disorder

   ADHD/ADD

   Aspergers

   Auditory Processing Disorder

   Autism Spectrum Disorder (ASD)

   Dyscalcuia

   Dysgraphia

   Dyslexia

   Graphomotor

   Language Processing Disorder

   Memory Disorder

   Other not listed - Neurodevelopmental/Cognitive Disorder

   Pervasive Development Disorder

   Social Pragmatic Disorder

   Specific Learning Disability (SLD)

   Specific Learning Disorder -- Math

   Specific Learning Disorder -- Reading

   Visual Processing and Integration Disorder

   Psychological

   Anorexia-nervosa

   Anxiety

   Bipolar Disorder

   Borderline Personality Disorder

   Bulimia Nervosa

   Conduct Disorder

   Depression

   Generalized Anxiety Disorder (GAD)

   Major Depressive Disorder (MDD)

   Obsessive Compulsive Disorder (OCD)

   Other not listed - Psychological

   Panic Disorder

   Paranoia

   Posttraumatic Stress Syndrome(PTSD)

   Schizoaffective Disorder

   Schizophrenia

   Tourette Syndrome

   Traumatic Brain Injury

   Traumatic Brain Injury

   Visual

   Blind

   Double Vision

   Low Vision

   Other not listed - Visual

   Vision Impairment
3. Other Disability or Note:
4. Seeking Degree: Select One Certificate Masters Degree Undergraduate
5. Major: Select One Accounting Applied Mathematics Biochemistry Biology Business Administration Business and Technology Management Business Communication Business Information Systems Chemistry Communication Studies Community-Based Education and Leadership Computer Information Systems Crime Scene Investigation Criminal Justice Cyber Forensics Digital Forensics Digital Marketing Early Childhood Education Elementary Education English Language and Literature Environmental Science Fashion Design Fashion Merchandising Film and the Moving Image Forensic Accounting Forensic Investigation Forensic Science Forensic Studies Graphic Design Healthcare Management Human Services Interdisciplinary Studies Legal Studies Marketing Medical Laboratory Science Middle School Education Nursing Pre-Dentistry Pre-Law Pre-Medicine Pre-Pharmacy Pre-Physical Therapy Pre-Veterinary Medicine Psychology Public History Sales Management and Technology Teaching (MAT) Theater and Media Performance Visual Communication Design

Affiliation(s)

6. Affiliation(s)

   Club Student Athlete

   First-Term Student

   Freshman

   International Student

   Junior

   Senior

   Sophomore

   Transfer Student

   Varsity Student Athlete

   Veteran

Ethnicity(ies)

7. Ethnicity(ies)

   African-American

   Asian or Pacific Islander

   Biracial

   Caucasian

   Hispanic

   Native American

   Other
8. Additional Note:

1.  

   Are you currently enrolled in classes at Stevenson University? * (Selection is Required)

   Yes

   No

   Additional Note or Comment
2. Please list the accommodations that you are requesting in the space below: * (Required)
3.  

   Please check any accommodations that you have used in the past (either in K-12 or at another College or University):

   Extra time for exams

   Reduced distraction for testing

   Assistive technology (text to speech; captioning, etc.)

   ASL, CART or other interpreting services

   Housing accommodations

   Note taking services

   Calculator use

   Laptop or access to word processing

   Reduced course load

   Other (Specify Below)

   Additional Note or Comment
4.  

   Are you requesting housing accommodations?

   Yes (Specify Below)

   No

   Additional Note or Comment
5. In your own words, please describe your disability and how it impacts your education: * (Required)
6. In your own words, please describe your disability and how it impacts your life: * (Required)
7. When was your disability diagnosed and by whom? * (Required)
8. If you play a varsity or club sport, please specify which sport below: * (Required)
9.  

   Have you received your COVID-19 vaccination? * (Selection is Required)

   Yes. Please include dates of vaccination dose(s). (Specify Below)

   Yes, but I have reason to believe the vaccination may not provide me with full protection. Please explain in detail, e.g. I have been told by my medical provider that the vaccination may not provide me with full protection due to taking immunosuppressants, etc. (Specify Below)

   In process. Please include the date of the first dose and the upcoming date of any further doses. (Specify Below)

   No, but I plan on being vaccinated before arriving on campus. Please include the date of your upcoming vaccination. (Specify Below)

   No, I do not plan on being vaccinated at this time. Please explain in the detail, e.g. I have (or am seeking) a medical, religious, or other exemption. (Specify Below)

   Additional Note or Comment