Thank you for your interest in our programs and services!

Please complete the form below so that we may be able to contact you and provide you with additional information.

Which campus are you interested in attending?

Individual's Name (required)

Contact Name (required)

Contact Telephone (required)

Address (required)

Contact Email (required)

How would you like us to contact you? (required)
 Email Telephone

Do you currently have services through any of the following state agencies/programs? (required)
 NOW/COMP Waiver Services Vocational Rehabilitation

If yes, please list the name of your support coordinator or VR Counselor

Type of disability (may select multiple) (required)
 Blind Deaf Intellectual Other Physical

Please indicate legal guardianship status
 Own Guardian Parent is Legal Guardian Other Guardianship