return false; } else if (obj_type == "SINGLE_VALUE_RADIO" || obj_type == "SINGLE_VALUE_CHECKBOX") { if (obj.checked) return true; else return false; } else if (obj_type == "RADIO" || obj_type == "CHECKBOX") { for (i=0; i < obj.length; i++) { if (obj[i].checked) return true; } return false; } } function _CF_checkform(_CF_this) { if (!_CF_hasValue(_CF_this.fname, "TEXT" )) { if (!_CF_onError(_CF_this, _CF_this.fname, _CF_this.fname.value, "You must provide your first name.")) { return false; } } if (!_CF_hasValue(_CF_this.lName, "TEXT" )) { if (!_CF_onError(_CF_this, _CF_this.lName, _CF_this.lName.value, "You must provide your last name.")) { return false; } } if (!_CF_hasValue(_CF_this.address, "TEXT" )) { if (!_CF_onError(_CF_this, _CF_this.address, _CF_this.address.value, "You must provide your mailing address.")) { return false; } } if (!_CF_hasValue(_CF_this.city, "TEXT" )) { if (!_CF_onError(_CF_this, _CF_this.city, _CF_this.city.value, "You must provide your city.")) { return false; } } if (!_CF_hasValue(_CF_this.state, "TEXT" )) { if (!_CF_onError(_CF_this, _CF_this.state, _CF_this.state.value, "You must provide your state.")) { return false; } } if (!_CF_hasValue(_CF_this.zip, "TEXT" )) { if (!_CF_onError(_CF_this, _CF_this.zip, _CF_this.zip.value, "You must provide a zipcode.")) { return false; } } if (!_CF_hasValue(_CF_this.email, "TEXT" )) { if (!_CF_onError(_CF_this, _CF_this.email, _CF_this.email.value, "Please enter a valid email address!")) { return false; } } if (!testbox(_CF_this, _CF_this.email, _CF_this.email.value)) { if (!_CF_onError(_CF_this, _CF_this.email, _CF_this.email.value, "Please enter a valid email address!")) { return false; } } if (!_CF_hasValue(_CF_this.dob, "TEXT" )) { if (!_CF_onError(_CF_this, _CF_this.dob, _CF_this.dob.value, "You must provide your date of birth.")) { return false; } } return true; } //-->

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Future Students

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Disability Services for Students

Educational Support Programs & Services
DISABILITY SERVICES for STUDENTS
Southwestern Oregon Community College
541-888-7405

If you would prefer to print the application, fill it out by hand, and return it to our office please click here.

ONLINE APPLICATION

Demographic Information
First Name
Last Name
Nickname
Address
City	State
Zip
Phone
Phone (message)
E-mail Address
Social Security Number
SOCC ID # (if you know it)
Date of Birth
Gender	Male Female
Ethnic Status	Caucasion Asian Hispanic or Latino Black or African-American American Indian or Alaskan Native Native Hawaiian or other Pacific Islander Other
Are you a U.S. citizen or permanent resident?	Yes No
Are you a U.S. veteran?	Yes No

Educational Funding
Are you currently receiving college financial aid?	Yes No Have applied
How are you financing your education?

Educational Information
Do you have?	High School Diploma GED Modified Diploma

Educational Goals
Enrolled (or will be) at SOCC:	Full-time (12 or more credits/term) Part-time
Program:	Certificate AAS AA/OT AS/OT AGS AS Transfer credits only
Major:
Academic Advisor's Name:
Do you plan to transfer to another school to get a four-year degree?	Yes No Undecided
Names of other colleges you are interested in attending after graduating or transferring from SOCC (if applicable):

Disability Information
*Please check if applicable and indicate if temporary* or permanent:**	Learning disability (Temporary) Learning disability (Permanent) Hard of hearing/deaf (Temporary) Hard of hearing/deaf (Permanent) Visual impairment (Temporary) Visual impairment (Permanent) Traumatic brain injury (Temporary) Traumatic brain injury (Permanent) Orthopedic/mobility disability (Temporary) Orthopedic/mobility disability (Permanent) Systemic health disability (Temporary) Systemic health disability (Permanent) ADHD (Temporary) ADHD (Permanent) Psychological (Temporary) Psychological (Permanent) Asperger's/Autism (Temporary) Asperger's/Autism (Permanent) Other (Temporary) Please describe: Other (Permanent) Please describe:
List reasonable accommodations reviewed in the past:

Other Information
How did you learn about Disability Services for Students at SOCC?	High School Transition Counselor SOCC Student Instructor College Recruiter Student First Stop Representative Coach SOCC Counselor Newmark Center Other
Where will you be attending classes?	Southwestern Main Campus Curry County Site Newmark Center

This application is filled out to the best of my knowledge. I understand that information I share with the Disability Services for Students (DSS) staff will be kept strictly confidential according to the rules and policies of the college. I also understand that information from all other offices at Southwestern Oregon Community College can be requested to complete my DSS file.

I understand that providing my name below serves as my signature for the purposes of this application.

Print Signature: Date:

Thanks for choosing Southwestern!

GO LAKERS!

Southwestern Oregon Community College is an equal opportunity educator and employer.

Questions? Contact Tim Dailey at tdailey@socc.edu

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Disability Services for Students

Educational Support Programs & Services DISABILITY SERVICES for STUDENTS Southwestern Oregon Community College 541-888-7405

Thanks for choosing Southwestern!

Educational Support Programs & Services
DISABILITY SERVICES for STUDENTS
Southwestern Oregon Community College
541-888-7405