Online Student Application

1. Start Term *: Select One 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Spring 2035 - Summer 2035 - Fall 2036 - Spring 2036 - Summer 2036 - Fall 2037 - Spring 2037 - Summer 2037 - Fall 2038 - Spring 2038 - Summer 2038 - Fall 2039 - Spring 2039 - Summer 2039 - Fall 2040 - Spring 2040 - Summer 2040 - Fall 2041 - Spring 2041 - Summer 2041 - Fall 2042 - Spring 2042 - Summer 2042 - Fall 2043 - Spring 2043 - Summer 2043 - Fall 2044 - Spring 2044 - Summer 2044 - Fall 2045 - Spring 2045 - Summer 2045 - Fall 2046 - Spring 2046 - Summer 2046 - Fall 2047 - Spring 2047 - Summer 2047 - Fall 2048 - Spring 2048 - Summer 2048 - Fall 2049 - Spring 2049 - Summer 2049 - Fall 2050 - Spring 2050 - Summer 2050 - Fall
   Note: Select when you would like to start your services.
2. Expected Graduation Term: Select One 2015 - Spring 2015 - Summer 2015 - Fall 2016 - Spring 2016 - Summer 2016 - Fall 2017 - Spring 2017 - Summer 2017 - Fall 2018 - Spring 2018 - Summer 2018 - Fall 2019 - Spring 2019 - Summer 2019 - Fall 2020 - Spring 2020 - Summer 2020 - Fall 2021 - Spring 2021 - Summer 2021 - Fall 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Spring 2035 - Summer 2035 - Fall 2036 - Spring 2036 - Summer 2036 - Fall 2037 - Spring 2037 - Summer 2037 - Fall 2038 - Spring 2038 - Summer 2038 - Fall 2039 - Spring 2039 - Summer 2039 - Fall 2040 - Spring 2040 - Summer 2040 - Fall 2041 - Spring 2041 - Summer 2041 - Fall 2042 - Spring 2042 - Summer 2042 - Fall 2043 - Spring 2043 - Summer 2043 - Fall 2044 - Spring 2044 - Summer 2044 - Fall 2045 - Spring 2045 - Summer 2045 - Fall 2046 - Spring 2046 - Summer 2046 - Fall 2047 - Spring 2047 - Summer 2047 - Fall 2048 - Spring 2048 - Summer 2048 - Fall 2049 - Spring 2049 - Summer 2049 - Fall 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. Username *:
8. Student ID *:
   Hint: Enter 9 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 Other/Not Specified
11. Pronouns: Select One he, him, his, his, himself per, per, pers, pers, perself she, her, her, hers, herself they, them, their, theirs, themself ve, ver, vis, vers, verself zie, hir, hir, hirs, hirself

1. Primary Phone Number:
   Hint: Enter 10-digit number only.
2. Secondary Phone Number:
   Hint: Enter 10-digit number only.
3. UTM 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 === Aneurysm Concussion Lack of oxygen Meningitis Near-drowning Other - Acquired Brain Injury Stroke Traumatic Brain Injury Tumor === ADD/ADHD === Other - ADD/ADHD === Autism Spectrum Disorder === Other - Autism Spectrum Disorder Other - Blind/Visually Impaired === Blind/Visually Impaired === Blind Visually Impaired === Chronic/Acute Health === Allergies/Asthma Autoimmune Disease Cancer Cardiovascular/Pulmonary Diabetes Gastrointestinal Organ, Blood, Tissue Other - Chronic/Acute Health Sickle cell anemia === Deaf/Hard of Hearing === Deaf Hard of Hearing Other - Deaf/Hard of Hearing === General Category === Other === Intellectual Disability === Developmental Delay Down Syndrome Fetal Alcohol Syndrome Fragile X Syndrome Other - Intellectual Disability Prader-Willi Syndrome === Learning Disability === Dysgraphia Dyslexia Math (Dyscalculia) Other- Learning Disability Reading Writing === Mental Health Impairment === Anxiety Bipolar Depression Eating Disorder Other - Mental Health Impairment Post Traumatic Stress Disorder (PTSD) Schizophrenia, Personality Disorders === Mobility Impairment === Arthritis Cerebral Palsy Multiple Sclerosis Musculoskeletal Injury Other- Mobility Impairment Parplegic Quadriplegic Spina bifida Spinal Cord Injury === Neurological/Nervous System === Fibromyalgia Migraine Other - Neurological/Nervous System Seizure Disorder === ODS Issued Assistive Technology === Glean Subscription License === Speech/Language === Articulation Disorder Expressive Language Disorder Mixed Expressive/Receptive Language Disorder Other - Speech/Language Receptive Language Disorder Voice Disorder
2. Secondary Disability(ies)

   Acquired Brain Injury

   Aneurysm

   Concussion

   Lack of oxygen

   Meningitis

   Near-drowning

   Other - Acquired Brain Injury

   Stroke

   Traumatic Brain Injury

   Tumor

   ADD/ADHD

   Other - ADD/ADHD

   Autism Spectrum Disorder

   Other - Autism Spectrum Disorder

   Other - Blind/Visually Impaired

   Blind/Visually Impaired

   Blind

   Visually Impaired

   Chronic/Acute Health

   Allergies/Asthma

   Autoimmune Disease

   Cancer

   Cardiovascular/Pulmonary

   Diabetes

   Gastrointestinal

   Organ, Blood, Tissue

   Other - Chronic/Acute Health

   Sickle cell anemia

   Deaf/Hard of Hearing

   Deaf

   Hard of Hearing

   Other - Deaf/Hard of Hearing

   General Category

   Other

   Intellectual Disability

   Developmental Delay

   Down Syndrome

   Fetal Alcohol Syndrome

   Fragile X Syndrome

   Other - Intellectual Disability

   Prader-Willi Syndrome

   Learning Disability

   Dysgraphia

   Dyslexia

   Math (Dyscalculia)

   Other- Learning Disability

   Reading

   Writing

   Mental Health Impairment

   Anxiety

   Bipolar

   Depression

   Eating Disorder

   Other - Mental Health Impairment

   Post Traumatic Stress Disorder (PTSD)

   Schizophrenia, Personality Disorders

   Mobility Impairment

   Arthritis

   Cerebral Palsy

   Multiple Sclerosis

   Musculoskeletal Injury

   Other- Mobility Impairment

   Parplegic

   Quadriplegic

   Spina bifida

   Spinal Cord Injury

   Neurological/Nervous System

   Fibromyalgia

   Migraine

   Other - Neurological/Nervous System

   Seizure Disorder

   ODS Issued Assistive Technology

   Glean Subscription License

   Speech/Language

   Articulation Disorder

   Expressive Language Disorder

   Mixed Expressive/Receptive Language Disorder

   Other - Speech/Language

   Receptive Language Disorder

   Voice Disorder
3. Other Disability or Note:
4. Seeking Degree: Select One Associates Degree Bachelors Degree Certificate Masters Degree Post Baccalaureate
5. Major: Select One Accounting B.S.B.A Agricultural Business B.S. Agriculture B.S. Biology B.S. Chemistry B.S. Communications B.A./B.S. Computer Science B.S. Counseling M.S. in Education Criminal Justice B.S. Economics B.S.B.A. Education Leadership M.S. in Education Engineering B.S. English B.A. Family and Consumer Science B.S. Family and Consumer Science M.S. Finance B.S.B.A. Fine and Performing Arts B.F.A. Geoscience B.S. Health & Human Performance B.S. History B.A./B.S. Information Systems B.S. Integrated Studies B.S.Ed. Interdisciplinary Studies B.I.S. Management B.S. in Business Administration Management in Business Administration M.B.A Mathematics B.A./B.S. Music B.A. Music B.M. Natural Resources Management B.S. Nursing B.S.N. Philosophy B.A. Political Science B.A./B.S. Pre-Nursing Pre-Podiatry Pre-Professional Biosystems Engineering Pre-Professional Chiropractic Pre-Professional Cytotechnology Pre-Professional Dental Hygiene Pre-Professional Dentistry Pre-Professional Health Informatics and Information Management Pre-Professional Law Pre-Professional Medical Pre-Professional Medical Laboratory Science Pre-Professional Occupational Therapy Pre-Professional Optometry Pre-Professional Pharmacy Pre-Professional Physical Therapy Pre-Professional Physicians Assistant Pre-Professional Theological Pre-Professional Veterinary Medicine Psychology B.A./B.S. Secondary Education B.S.Ed. Social Work B.S.S.W. Sociology B.A./B.S. Spanish B.A. Special Education B.S.Ed. Strategic Communications M.A. Teaching M.S. in Education

Affiliation(s)

6. Affiliation(s)

   Dual-Enrollment Student

   Fraternity/Sorority Member

   Graduate Student (Master's Level)

   Internship/Clinicals/Field Placement

   Jackson Center

   Off-Campus Resident

   On-Campus Resident

   Parsons Center

   PEP Leader

   Ripley Center

   Selmer Center

   SI Tutor (Supplemental Instruction)

   Somerville Center

   Student Athlete

   Student Government Member

   Student Worker - Work Study or Departmentally Funded

   Study Abroad

   Transfer Student

   TRiO

   Tuition Fees Disability Waiver

   Undergraduate Student (Bachelor's Level)

   UT Online

   Veteran or Active Duty Member of the Military

   Vocational Rehabilitation

Ethnicity(ies)

7. Ethnicity(ies)

   American Indian or Alaska Native

   Asian

   Black or African American

   Hispanic or Latino

   Native Hawaiian or Other Pacific Islander

   Other

   Prefer not to report

   White

Campus Location(s)

8. Campus Location(s)

   University of Tennessee at Martin
9. Additional Note: