Online Student Application

In order to be connected with the Disability Resource Center (DRC) and to receive accommodations students will first need to complete and submit the registration form below.

TMCC is committed to keeping sensitive disability-related information confidential, and information is only released on a need-to-know basis unless a student specifically gives us permission to share information with specific individuals or entities. The only exception to this policy is set forth in law and regulation, allowing records to be inspected by regulatory, enforcement or evaluative bodies and to be released as ordered by a court.

Please review the Student Rights and Responsibilites and the High School Transition Guide before submitting this registration form. By submitting this form, you are acknowledging that you have received notice of your rights and responsibilities.

Personal Information

First Name *:
Last Name *:
Middle Name:
Optional: Preferred Name:
Student ID:
Hint: Enter 10 alpha numeric characters.
Birth Date:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Gender *:
Start Term *:
Note: Select when you would like to start your services.
Expected Graduation Term:
Note: Select when you plan to graduate.

Contact Information

Primary Phone Number:
Hint: Enter 10-digit number only.
Secondary Phone Number:
Hint: Enter 10-digit number only.
Email Address *:
Please note that we will send all email correspondence to your school email address whenever possible. (your_name@mail.tmcc.edu).

Local Address

Address *:
City *:
State *:
Zipcode *:
Hint: Enter zipcode as 97331 or 97331-0000.

Permanent Address

Same as Local Address

Address:
City:
State:
Zipcode:
Hint: Enter zipcode as 97331 or 97331-0000.

Additional Information

Questions

How has your disability made success in school difficult to achieve? Please describe. * (Required)
What accommodations have you received in the past? At what institution? * (Required)
What assistive technology devices have you been trained to use? (text to speech software, smartpens, etc.) * (Required)
Would you like to be assessed for areas where technology may be used to help you overcome challenges related to your disability? * (Selection is Required)

Yes

No

Additional Note or Comment
What accommodations are you interested in receiving at TMCC? * (Required)
Are you taking any medication at the present time? * (Selection is Required)

Yes (Specify Below) Name of medication, dosage, reason for taking, side effects?

No

Additional Note or Comment
What is your career goal? * (Required)
How many credits are you currently enrolled at TMCC? Other Institution? * (Required)
Are you a participant in any scholarships or programs with a credit requirement? * (Selection is Required)

Yes (Specify Below) Please indicate the program and how many credits you are required to take.

No

Additional Note or Comment
How did you hear about our program? * (Required)

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