Special Population Survey
REQUIRED TO BE COMPLETED BY ALL NEW CREDIT STUDENTS
Student I.D. Number
*
Click on the line and type your Student I.D. Number
Full Name
*
First Name
Middle Name
Last Name
Suffix
E-mail
Please provide a valid email address that you check on a daily basis.
Click to Answer Yes on All of the Below Questions That Apply:
Do you have a physical or mental impairment which substantially limits one or more major life activities such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, or learning?
Yes
No
Do you have a language other than English as your primary language and do you have a limited ability to write or understand English?
Yes
No
Are you a person who has the primary or joint custody for a dependent child? You may be divorced, widowed, legally separated, never married or a person who is single and pregnant.
Yes
No
Are you a person who has cared for a home and family without pay; who has been financially supported by another family member in the past; who is unemployed or underemployed and having difficulty in obtaining and upgrading employment or who has a custody of a child with less than two years remaining to receive assistance from Title IV of the Social Security Act?
Yes
No
Do you wish to disclose this information to West Georgia Technical College staff?
Yes
No
I am working toward a:
*
Certificate
Diploma
Degree
Submit
Should be Empty: