Student Information Form
Name
*
First Name
Last Name
Date
*
/
Month
/
Day
Year
Date
S#
*
Initials
*
Preferred Name
*
Preferred Pronouns
He, him, his/She, her, hers\Them, they, theirs
Date of Birth
*
/
Month
/
Day
Year
Date
Personal E mail
*
example@example.com
Otero Student E mail
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Are you registered to vote?
*
Yes
No
Would you like to register to vote today?
*
Yes
No
Are you a Military Veteran?
*
Yes
No
What is your disability or diagnosis?
*
During your K-12 schooling, did you have an IEP or 504 Plan?
*
Yes
No
Please list any accommodations or assistance that you have found helpful in the past.
Please describe any difficulties or challenges you are having or anticipate having in college.
What is your major?
*
How did you hear about Accessibility Services at Otero?
*
Please give any additional information that would be helpful in providing you with theappropriate accommodations and services.
Submit
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