Online Student Application

1. Start Term *: Select One 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall
   Note: Select when you would like to start your services.
2. Expected Graduation Term: Select One 2005 - Spring 2005 - Summer 2005 - Fall 2006 - Spring 2006 - Summer 2006 - Fall 2007 - Spring 2007 - Summer 2007 - Fall 2008 - Spring 2008 - Summer 2008 - Fall 2009 - Spring 2009 - Summer 2009 - Fall 2010 - Spring 2010 - Summer 2010 - Fall 2011 - Spring 2011 - Summer 2011 - Fall 2012 - Spring 2012 - Summer 2012 - Fall 2013 - Spring 2013 - Summer 2013 - Fall 2014 - Spring 2014 - Summer 2014 - Fall 2015 - Spring 2015 - Summer 2015 - Fall 2016 - Spring 2016 - Summer 2016 - Fall 2017 - Spring 2017 - Summer 2017 - Fall 2018 - Spring 2018 - Summer 2018 - Fall 2019 - Spring 2019 - Summer 2019 - Fall 2020 - Spring 2020 - Summer 2020 - Fall 2021 - Spring 2021 - Summer 2021 - Fall 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall
   Note: Select when you plan to graduate.
3. First Name *:
4. Last Name *:
5. Middle Name:
6. Optional: Preferred Name:
7. Student ID:
   Hint: Enter 10 alpha numeric characters.
8. Birth Date:
   Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
9. Gender *: Select One Female Male Not Specified
10. Pronouns: Select One he/him/his she/her/hers they/them/their

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

1. Address *:
2. City *:
3. State *: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode *:
   Hint: Enter zipcode as 97331 or 97331-0000.

Same as Local Address

1. Address:
2. City:
3. State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode:
   Hint: Enter zipcode as 97331 or 97331-0000.

1. Primary Disability *: Select One === Chronic Illness === Arthritis Diagnosis Asthma Cardio/Pulmonary Disease Carpal Tunnel Syndrome Chrons Disease Cystic Fibrosis Diabetes Fibromyalgia Hypertension - severe IBS Lupus Other Chronic Diagnosis === Cognitive Impariment === Cognitive Diagnosis NOS Memory -Short Term TBI === Deaf/Hard of Hearing === Acute Tinnitus Deaf and Blind Deaf Oral Deaf uses Sign Language Hard of Hearing Late Deafened === General Category === Other === Learning Disorder === Developmental Coordination Disorder Dysgraphia Dyslexia LD NOS Mathematics Disorder Reading Comprehension Reading Fluency Spelling Written Expression === Neurological === ADHD (Inattentive/Hyper/Combined) Auditory Processing Disorder Irlen Syndrome/Scotopic Sensitivity Multiple Sclerosis Narcolepsy Neurological DO NOS Neurological DX Seizure Disorder Slower Cognitive Processing/Organization DO === Physical Dexterity === Minimal use of upper arm(s)/hand(s)/fingers Other Dexterity Diagnosis === Physical Mobility === Cerebral Palsy Charcot-Marie-Tooth Disease Other Mobility Diagnosis Paraplegia Quadraparaplegia === Psychological Disorder === Adjustment Disorder Anxiety Asperger/Autism Spectrum Bi Polar Clinical Depression Complex PTSD OCD Other Psychological Diagnosis Panic Disorder Personality Disorder PTSD === Speech/Language === Communication Disorder Other Sp/Lng Diagnosis Speech Impairment === Visual === Blind Nystigmus Ocular Albinism Other Visual Diagnosis Vision Diagnosis Visual Acuity Visual Perception Disorder
2. Secondary Disability(ies)

   Chronic Illness

   Arthritis Diagnosis

   Asthma

   Cardio/Pulmonary Disease

   Carpal Tunnel Syndrome

   Chrons Disease

   Cystic Fibrosis

   Diabetes

   Fibromyalgia

   Hypertension - severe

   IBS

   Lupus

   Other Chronic Diagnosis

   Cognitive Impariment

   Cognitive Diagnosis NOS

   Memory -Short Term

   TBI

   Deaf/Hard of Hearing

   Acute Tinnitus

   Deaf and Blind

   Deaf Oral

   Deaf uses Sign Language

   Hard of Hearing

   Late Deafened

   General Category

   Other

   Learning Disorder

   Developmental Coordination Disorder

   Dysgraphia

   Dyslexia

   LD NOS

   Mathematics Disorder

   Reading Comprehension

   Reading Fluency

   Spelling

   Written Expression

   Neurological

   ADHD (Inattentive/Hyper/Combined)

   Auditory Processing Disorder

   Irlen Syndrome/Scotopic Sensitivity

   Multiple Sclerosis

   Narcolepsy

   Neurological DO NOS

   Neurological DX

   Seizure Disorder

   Slower Cognitive Processing/Organization DO

   Physical Dexterity

   Minimal use of upper arm(s)/hand(s)/fingers

   Other Dexterity Diagnosis

   Physical Mobility

   Cerebral Palsy

   Charcot-Marie-Tooth Disease

   Other Mobility Diagnosis

   Paraplegia

   Quadraparaplegia

   Psychological Disorder

   Adjustment Disorder

   Anxiety

   Asperger/Autism Spectrum

   Bi Polar

   Clinical Depression

   Complex PTSD

   OCD

   Other Psychological Diagnosis

   Panic Disorder

   Personality Disorder

   PTSD

   Speech/Language

   Communication Disorder

   Other Sp/Lng Diagnosis

   Speech Impairment

   Visual

   Blind

   Nystigmus

   Ocular Albinism

   Other Visual Diagnosis

   Vision Diagnosis

   Visual Acuity

   Visual Perception Disorder
3. Other Disability or Note:
4. Seeking Degree: Select One Master Degree Ph.D. Degree Post Baccalaureate Undergraduate
5. Major: Select One Accountancy Accounting Applied Arts and Sciences Art Art (Art History) Art (Studio) Biology Business Administration Chemistry Civil Engineering Clinical Psychology Communication Computer Information Systems Computer Science Construction Management Counseling Psychology Criminal Justice Curriculum & Instruction Economics Educational Leadership Electrical Engineering English Finance General Studies Health & Kinesiology Health Professions History Human Resource Development Industrial Technology Interdisciplinary Studies Journalism Kinesiology Management Marketing Mathematics Mechanical Engineering Music Nursing Pharmacy Political Science Psychology Public Administration Reading Religion Studies School Counseling Social Sciences Spanish Special Education Speech Communication Technology

Affiliation(s)

6. Affiliation(s)

   Athlete

   CAP Student

   Commission for the Blind

   Dept of Assistive/Rehabilitative Services (DARS)

   Greek Group

   Transfer Student

   University Academy

   Veterans Administration

Ethnicity(ies)

7. Ethnicity(ies)

   African American

   Asian American

   European American

   Hispanic American

   International Student

   Middle Eastern American

   Native American

Campus Location(s)

8. Campus Location(s)

   Houston Campus

   Longview Campus

   Palestine Campus

   Tyler- Main Campus

   UT Health
9. Additional Note: