Native Language

Name: / Student ID: / S
Last / First / Middle Initial
Address:
Street / City / State / Zip Code
Home Phone: / ( ) / Cell Phone: / ( )
Student Email: / @student.cccs.edu / Birth Date:
Gender: / Employed: / Y N (Circle One)

Native Language:

English Other ______

Emergency Contact: / Relationship / Phone:
( )

Education:

Special programs attended: Special Ed Special Classes

Education Level:

High School Diploma (year______) / High School Non-Graduate
GED (year______) / Attended Some College
Currently in High School / College Graduate (year______)
Degree ______

Educational Goal: (see ACC Catalog)

Associate of Art (AA) / Associate of Applied Science Degree (AAS)
Associate of Science (AS) / Associate of Applied Science Certificate (AAS)
Associate of General Studies (AGS) / Major Declared:______
Job-related skill upgrade / Transfer:______
Other / Certificate Program:______

ACC Status:

Have you taken the CCPT to assess your academic skills? Yes No (Limited exemptions on a case-by-case basis.)

Anticipated test date: ______(Registration is dependent upon CCPT scores.)

Have you met with an Academic Adviser? Yes NoReferred by:

Have you applied for Financial Aid? Yes No______

Are you registered for classes? Yes No Fall ______Spring ______Summer ______

Community Services:

Are you receiving services from community, state or federal agencies? Yes No

Agency / Contact Person / Phone Number

Disability Information: If you are a student who would like to self-disclose a disability, please respond to the following:

My disability is… Diagnosed Suspected, not diagnosed

If diagnosed or suspected, describe the academic impact of your disability: ______

______

Disability Classification: If you have multiple disabilities, please indicate your primary disability first and list any others that are applicable.

______

______

______

______

Initial Diagnosis Date:______Origin of Disability: Congenital Illness Injury

List any medications you are currently taking and how they may affect your academic work:

______

List Assistive Technology preferences: ______

I hereby authorize Student Access Services (SAS) to hold confidential information on this form, any records I provide, as well as information shared by me or on my behalf with SAS staff. Information provided to SAS will not become part of my academic record, but will remain in a limited-access file. Additionally, I authorize SAS to share information from these records with other Arapahoe Community College staff members or volunteers on a need to know basis in order to assist in the provision of services. I understand my records may be released to off-campus authorities as required by law. I further understand these records are necessary in the determination of special services, statistical reporting and funding purposes.

Student Signature / Date
SAS Specialist Signature / Date
Intake Form / 1

_____SAS Code ______Add Student to Campus Police Emergency List