Online Student Application

1. Start Term *: Select One 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. Student ID:
   Hint: Enter 9 alpha numeric characters.
8. Birth Date:
   Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
9. 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. Email Address *:
   Hint: Winthrop Address (preferred).

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 ADD/ADHD (AD) - AD - ADD & ADHD Allergies (AL) - AL - Celiac Disease Allergies (AL) - AL - Other (see note) Allergies (AL) - AL - Severe Allergies (Environmental) Allergies (AL) - AL - Severe Allergies (Food) Autism Spectrum (AS) - AS - Autism Spectrum Deaf/Hard of Hearing (DH) - DH - D/deaf Deaf/Hard of Hearing (DH) - DH - Hard-of-Hearing General Category - NC - No Code Listed Intellectual Disability (ID) - ID - Borderline Intellectual Functioning Intellectual Disability (ID) - ID - Intellectual Disability Intellectual Disability (ID) - ID - TOPS Learning Disability (LD) - LD - Auditory Processing Learning Disability (LD) - LD - Dysgraphia Learning Disability (LD) - LD - Dyslexia Learning Disability (LD) - LD - Mathematics Learning Disability (LD) - LD - NOS Learning Disability (LD) - LD - Processing Speed Learning Disability (LD) - LD - Reading Learning Disability (LD) - LD - Visual Processing Learning Disability (LD) - LD - Visual-Motor Learning Disability (LD) - LD - Written Expression Medical (MD) - MD - Arthritis Medical (MD) - MD - Asthma Medical (MD) - MD - Cancer Medical (MD) - MD - Carpal Tunnel Syndrome Medical (MD) - MD - Cerebral Palsy Medical (MD) - MD - Chronic Fatigue Medical (MD) - MD - Chronic Pain Disorder Medical (MD) - MD - Crohn's Disease Medical (MD) - MD - Cystic Fibrosis Medical (MD) - MD - Diabetes Medical (MD) - MD - Ehlers-Danlos Syndrome Medical (MD) - MD - Epilepsy Medical (MD) - MD - Fibromyalgia Medical (MD) - MD - HIV/AIDS Medical (MD) - MD - Irritable Bowel Syndrome (IBS) Medical (MD) - MD - Lupus Medical (MD) - MD - Migraines Medical (MD) - MD - Multiple Scelrosis Medical (MD) - MD - Muscular Dystrophy Medical (MD) - MD - Narcolepsy Medical (MD) - MD - Other (see note) Medical (MD) - MD - Postconcussional Syndrome Medical (MD) - MD - Postural Orthostatic Tachycardia Syndrome (POTS) Medical (MD) - MD - Sleep Apnea Medical (MD) - MD - Sleep Disorder - other (see note) Medical (MD) - MD - Spina Bifida Medical (MD) - MD - Stroke Medical (MD) - MD - Tinnitus Medical (MD) - MD - Traumatic Brain Injury (TBI) Medical (MD) - MD - Tumor(s) Medical (MD) - MD - Ulcerative Colitis Mobility Impairment (MI) - MI - Amputation Mobility Impairment (MI) - MI - Other (see note) Mobility Impairment (MI) - MI - Paraplegia Mobility Impairment (MI) - MI - Quadriplegia Psychological (PS) - PS - Adjustment Disorder Psychological (PS) - PS - Anxiety (GAD) Psychological (PS) - PS - Bipolar Disorder Psychological (PS) - PS - Borderline Personality Disorder Psychological (PS) - PS - Collegiate Recovery Community Psychological (PS) - PS - Depression Psychological (PS) - PS - Eating Disorder Psychological (PS) - PS - Mood Disorder Psychological (PS) - PS - Obsessive Compulsive Disorder (OCD) Psychological (PS) - PS - Other (see note) Psychological (PS) - PS - Panic Disorder Psychological (PS) - PS - Post Traumatic Stress Disorder (PTSD) Psychological (PS) - PS - Schizophrenia Psychological (PS) - PS - Social Anxiety Psychological (PS) - PS - Social Phobia Psychological (PS) - PS - Specific Phobia Psychological (PS) - PS - Tourette's Disorder Speech/Language Disorders (SL) - SL - Other (see note) Speech/Language Disorders (SL) - SL - Stuttering Temporary (TM) - TM - Broken Bone or Sprain Temporary (TM) - TM - Concussion Temporary (TM) - TM - Other (see note) Temporary (TM) - TM - Post-surgery Visual Impairment (VI) - VI - Blind (see note) Visual Impairment (VI) - VI - Convergence Disorder or Insufficiency Visual Impairment (VI) - VI - Low Vision (see note)
2. Secondary Disability(ies)

   ADD/ADHD (AD)

   AD - ADD & ADHD

   Allergies (AL)

   AL - Celiac Disease

   AL - Other (see note)

   AL - Severe Allergies (Environmental)

   AL - Severe Allergies (Food)

   Autism Spectrum (AS)

   AS - Autism Spectrum

   Deaf/Hard of Hearing (DH)

   DH - D/deaf

   DH - Hard-of-Hearing

   General Category

   NC - No Code Listed

   Intellectual Disability (ID)

   ID - Borderline Intellectual Functioning

   ID - Intellectual Disability

   ID - TOPS

   Learning Disability (LD)

   LD - Auditory Processing

   LD - Dysgraphia

   LD - Dyslexia

   LD - Mathematics

   LD - NOS

   LD - Processing Speed

   LD - Reading

   LD - Visual Processing

   LD - Visual-Motor

   LD - Written Expression

   Medical (MD)

   MD - Arthritis

   MD - Asthma

   MD - Cancer

   MD - Carpal Tunnel Syndrome

   MD - Cerebral Palsy

   MD - Chronic Fatigue

   MD - Chronic Pain Disorder

   MD - Crohn's Disease

   MD - Cystic Fibrosis

   MD - Diabetes

   MD - Ehlers-Danlos Syndrome

   MD - Epilepsy

   MD - Fibromyalgia

   MD - HIV/AIDS

   MD - Irritable Bowel Syndrome (IBS)

   MD - Lupus

   MD - Migraines

   MD - Multiple Scelrosis

   MD - Muscular Dystrophy

   MD - Narcolepsy

   MD - Other (see note)

   MD - Postconcussional Syndrome

   MD - Postural Orthostatic Tachycardia Syndrome (POTS)

   MD - Sleep Apnea

   MD - Sleep Disorder - other (see note)

   MD - Spina Bifida

   MD - Stroke

   MD - Tinnitus

   MD - Traumatic Brain Injury (TBI)

   MD - Tumor(s)

   MD - Ulcerative Colitis

   Mobility Impairment (MI)

   MI - Amputation

   MI - Other (see note)

   MI - Paraplegia

   MI - Quadriplegia

   Psychological (PS)

   PS - Adjustment Disorder

   PS - Anxiety (GAD)

   PS - Bipolar Disorder

   PS - Borderline Personality Disorder

   PS - Collegiate Recovery Community

   PS - Depression

   PS - Eating Disorder

   PS - Mood Disorder

   PS - Obsessive Compulsive Disorder (OCD)

   PS - Other (see note)

   PS - Panic Disorder

   PS - Post Traumatic Stress Disorder (PTSD)

   PS - Schizophrenia

   PS - Social Anxiety

   PS - Social Phobia

   PS - Specific Phobia

   PS - Tourette's Disorder

   Speech/Language Disorders (SL)

   SL - Other (see note)

   SL - Stuttering

   Temporary (TM)

   TM - Broken Bone or Sprain

   TM - Concussion

   TM - Other (see note)

   TM - Post-surgery

   Visual Impairment (VI)

   VI - Blind (see note)

   VI - Convergence Disorder or Insufficiency

   VI - Low Vision (see note)
3. Other Disability or Note:
4. Seeking Degree: Select One Bachelors Degree Certificate Masters Degree Post Baccalaureate

Affiliation(s)

5. Affiliation(s)

   Honors

   Student Athlete

   Study Abroad

   ThinkCollege

   Transfer

   TRiO

   Veteran
6. Additional Note: