Online Student Application

Please fill out the application form the best you can. If you are unsure of some information you may skip it and it can be covered in your intake appointment. This is the first step, you will be contacted via your Patriot Email after your application is reviewed and asked to make an intake appointment to complete the eligibility process.

Personal Information

Start Term *:
Note: Select when you would like to start your services.
Expected Graduation Term:
Note: Select when you plan to graduate.
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 *:

Contact Information

Primary Phone Number:
Hint: Enter 10-digit number only.
Secondary Phone Number:
Hint: Enter 10-digit number only.
Email Address *:

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

Check the accommodations or modifications you have previously received in school or college:

Prior Accommodations

Check the accommodations you are requesting here on the Univeristy of Texas at Tyler campus:

Requesting Accommodations at SAR

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Student Accessibility and Resources

University of Texas at Tyler
University Center Room 3150
Tyler, TX 75799

Website: http://www.uttyler.edu/disabilityservices/
Email Us: UTTyler-SAR@AccessibleLearning.com

Phone: (903) 566 - 7079
Fax: (903) 565 - 5592

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