Access Program Application

Access Program Application

Please submit application below before August 5, 2022.
Student and Parent/Guardian Information
Lincoln College Student ID
Student Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Student Phone Number *
Please enter a valid phone number.
Student Email *
example@example.com
High School Graduation Date

Month Day Year
Date
Parent/Guardian Name *

First Name Last Name
Parent/Guardian Phone Number *
Please enter a valid phone number.
Parent/Guardian Email *
example@example.com

History of Support Services and Accomodations
Please list any special education support services that you received at other schools or privately: *
If any special education support services were particularly helpful, please describe: *
Please list any related support services received (e.g. counseling, tutors, therapy, etc.): *
Have you ever attended school in a self-contained classroom, taken classes in a resource room, or been enrolled in a specialized school? If yes, please describe: *

Diagnostic Information
What is your primary diagnosis and when were you diagnosed? *
Please list any social or behavioral issues you may have experienced. Examples may include anxiety, depression, inappropriate social interaction, periods of antisocial behavior, anger, or general misconduct: *
Describe the steps that have been taken, so far, to resolve the social/behavioral problem: *

Agreement and Checklist
I, First Name* Last Name* , would like to register for the Access Program. I understand that there is a fee of $2,250 per semester that I am registered with the program. I understand that the fee is non-refundable once the semester has begun, unless there are extenuating circumstances. In these instances, and at the sole discretion of the college, a partial refund may be given in accordance with the general credit/refund policy as stated in the Undergraduate Catalog.
Please indicate the statement below that best describes your Access enrollment and Access Prep Week attendance. Choose one of the following arrangements: *

I will be a new Access Student before this upcoming fall semester. I will be attending Access Prep Week prior to my first fall semester. I am a returning Access Student. I am not required to attend Access Prep Week.
Student Signature *

Clear
Parent/Guardian Signature *

Clear
Should be Empty:

Student and Parent/Guardian Information