Online Student Application

1. Start Term *: Select One 2024 - Spring 2024 - Summer 2024 - Fall 2025 - J-Term 2025 - Spring 2025 - Summer 2025 - Fall 2026 - J-Term 2026 - Spring 2026 - Summer 2026 - Fall 2027 - J-Term 2027 - Spring 2027 - Summer 2027 - Fall 2028 - J-Term 2028 - Spring 2028 - Summer 2028 - Fall 2029 - J-Term 2029 - Spring 2029 - Summer 2029 - Fall 2030 - J-Term 2030 - Spring 2030 - Summer 2030 - Fall 2031 - J-Term 2031 - Spring
   Note: Select when you would like to start your services.
2. Expected Graduation Term: Select One 2010 - Summer 2010 - Fall 2011 - J-Term 2011 - Spring 2011 - Summer 2011 - Fall 2012 - J-Term 2012 - Spring 2012 - Summer 2012 - Fall 2013 - J-Term 2013 - Spring 2013 - Summer 2013 - Fall 2014 - J-Term 2014 - Spring 2014 - Summer 2014 - Fall 2015 - J-Term 2015 - Spring 2015 - Summer 2015 - Fall 2016 - J-Term 2016 - Spring 2016 - Summer 2016 - Fall 2017 - J-Term 2017 - Spring 2017 - Summer 2017 - Fall 2018 - J-Term 2018 - Spring 2018 - Summer 2018 - Fall 2019 - J-Term 2019 - Spring 2019 - Summer 2019 - Fall 2020 - J-Term 2020 - Spring 2020 - Summer 2020 - Fall 2021 - J-Term 2021 - Spring 2021 - Summer 2021 - Fall 2022 - J-Term 2022 - Spring 2022 - Summer 2022 - Fall 2023 - J-Term 2023 - Spring 2023 - Summer 2023 - Fall 2024 - J-Term 2024 - Spring 2024 - Summer 2024 - Fall 2025 - J-Term 2025 - Spring 2025 - Summer 2025 - Fall 2026 - J-Term 2026 - Spring 2026 - Summer 2026 - Fall 2027 - J-Term 2027 - Spring 2027 - Summer 2027 - Fall 2028 - J-Term 2028 - Spring 2028 - Summer 2028 - Fall 2029 - J-Term 2029 - Spring 2029 - Summer 2029 - Fall 2030 - J-Term 2030 - Spring 2030 - Summer 2030 - Fall 2031 - J-Term 2031 - Spring
   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 8 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 Prefer to not disclose
10. Pronouns: Select One Them/they/theirs

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 === ADHD === Attention Deficit Disorder (ADD) Attention Deficit Hyperactivity Disorder (ADHD) === Autism Spectrum Disorder === Asperger's Syndrome Autism Pervasive Developmental Delay (PDD) Sensory Integration Disorder === Brain Injury === Cerebral Palsy Concussion Encephalopathy Epilepsy Gerstmann Syndrome Hemiplegia/Hemiparesis Multiple Sclerosis Post-Concussive Syndrome Stroke Traumatic Brain Injury Tumor/Surgery === General Category === Other === Hearing Impaired === Deaf Hard of Hearing Hearing Aids === Learning Disability === Auditory Processing Disorder Cognitive disorder, NOS Dyslexia/Dyscalculia/Dysgraphia Learning Disorder, NOS Specific Learning Disorder === Physical === Cancer (Current or former diagnosis) Carpal Tunnel Syndrome Migraines Mobility Impaired Muscular Dystrophy Other Medical Condition Partially or Completely Missing Limbs Physical Injury Physical injury - Temporary Spina Bifida === Psychological === Adjustment Disorder Bipolar Disorder Depressive Disorder Generalized Anxiety Disorder Obsessive Compulsive Disorder (OCD) Oppositional Defiant Disorder (ODD) Post Traumatic Stress Disorder (PTSD) Schizophrenia === Systemic === Arthritis Crohn's Disease/Ulcerative Colitis/IBS Diabetes Environmental Allergies Fibromyalgia Food Allergies Graves Disease HIV Infection/AIDS Sickle Cell Disease Thyroid issues === Vision === Blind Low Vision
2. Secondary Disability(ies)

   ADHD

   Attention Deficit Disorder (ADD)

   Attention Deficit Hyperactivity Disorder (ADHD)

   Autism Spectrum Disorder

   Asperger's Syndrome

   Autism

   Pervasive Developmental Delay (PDD)

   Sensory Integration Disorder

   Brain Injury

   Cerebral Palsy

   Concussion

   Encephalopathy

   Epilepsy

   Gerstmann Syndrome

   Hemiplegia/Hemiparesis

   Multiple Sclerosis

   Post-Concussive Syndrome

   Stroke

   Traumatic Brain Injury

   Tumor/Surgery

   General Category

   Other

   Hearing Impaired

   Deaf

   Hard of Hearing

   Hearing Aids

   Learning Disability

   Auditory Processing Disorder

   Cognitive disorder, NOS

   Dyslexia/Dyscalculia/Dysgraphia

   Learning Disorder, NOS

   Specific Learning Disorder

   Physical

   Cancer (Current or former diagnosis)

   Carpal Tunnel Syndrome

   Migraines

   Mobility Impaired

   Muscular Dystrophy

   Other Medical Condition

   Partially or Completely Missing Limbs

   Physical Injury

   Physical injury - Temporary

   Spina Bifida

   Psychological

   Adjustment Disorder

   Bipolar Disorder

   Depressive Disorder

   Generalized Anxiety Disorder

   Obsessive Compulsive Disorder (OCD)

   Oppositional Defiant Disorder (ODD)

   Post Traumatic Stress Disorder (PTSD)

   Schizophrenia

   Systemic

   Arthritis

   Crohn's Disease/Ulcerative Colitis/IBS

   Diabetes

   Environmental Allergies

   Fibromyalgia

   Food Allergies

   Graves Disease

   HIV Infection/AIDS

   Sickle Cell Disease

   Thyroid issues

   Vision

   Blind

   Low Vision
3. Other Disability or Note:
4. Seeking Degree: Select One Certificate Masters Degree Ph.D. Degree Post Baccalaureate Undergraduate
5. Major: Select One Acting/Directing Anthropology Art History Biology Business Administration Chemistry Chinese Studies Classics Communication Computer Science & Computer Engineering Design/Technical Theatre Doctor of Nursing Practice Economics Education Engineering Science (3-2) English Environmental Studies French Geosciences German Global Studies Hispanic Studies History Kinesiology Master of Arts in Education: Advancing Current Teachers Master of Arts in Education: Preparing New Teachers Master of Arts in Marriage and Family Therapy Master of Business Administration Master of Fine Arts: Rainier Writing Workshop Master of Science in Finance Master of Science in Marketing Research Master of Science in Nursing Mathematics Music Music Education Music-Performance Musical Arts Norwegian Nursing Philosophy Physics Political Science Psychology Religion Scandinavian Area Studies Social Work Sociology Studio Arts Undeclared Women's & Gender Studies

Ethnicity(ies)

6. Ethnicity(ies)

   African-American

   Asian or Pacific Islander

   European-American

   Hispanic

   Multi-Racial

   Native American

   Other
7. Additional Note: