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PREP 2020
Please fill out the attached application by going online or by
mailing, faxing, or emailing it at least one week prior to the
PREP date you choose. There is limited space so please
consider submitting it at your earliest convenience. Once your
application is received, you will receive a confirmation at the email
you provide. Two weeks prior to the date of the program, you will
receive detailed information about registration times, locations,
and other important program details.
For questions or assistance completing the application, please
call the MVCC Office of Accessibility Resources at 315-792-5644
(Utica) or 315-334-7744 (Rome)
Submit by:
Mohawk Valley Community College
Office of Accessibility Resources
1101 Sherman Drive
Utica, NY 13501
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MVCC 2020 PREP Program Application
I plan to attend the program on (check ONE you plan to attend)
____ August 13 ___ August 20
Name ________________________________________ Preferred Name ________________________
First Last
Address ______________________________ City _____________ State ______ Zip _____________
County ________________________
Primary Phone ( _____ ) ________ - __________ Alternate Phone ( _____ ) ________ - __________
Date of Birth ____/____/______ Primary Email Address ___________________________________
How do you identify? ____ He/Him/His ____ She/Her/Hers ____ They/Them/Theirs
Are you planning to attend MVCC ____ Fall 2020 ____ Spring 2020
Do you plan to live on campus? ____ Yes ____ No
Do you have an open ACCES-VR Case? ____ Yes ____ No
Additional Information (optional)
Are you Hispanic or Latino? ___ Yes ___ No
How would you describe your racial background (Select all that apply)
___ Asian
___ Black or African American
___ American Indian or Alaska Native
___ Native Hawaiian or Other Pacific Islander
___ White
About Your Education
Name(s) of School
City & State
Date of Attendance
(from-to) Month/Year
Date or Expected Date
of Graduation
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Have you been diagnosed with a learning disability, AD/HD, or ASD? ____ Yes ____ No
If yes, what is the diagnosis? If no, what is your documented disability? _____________________
Do you/did you have an Individualized Education Plan (IEP) or 504 in high school? ___ Yes ___ No
Have you ever attended college? ____ Yes ____ No If yes, where/when?_____________________
Did you receive accommodative services? If yes, what were they ___Yes ___ No
What academic courses do you find most difficult? ________________________________________
What aspect of school challenges you the most?
___ Note taking ___ Test taking ___ Staying Organized
___ Studying ___ Focusing ___ Time management
___ Reading ___ Socializing/Communicating Other ____________________
What skills and strategies do you hope to develop by participating in MVCC’s Transition Day?
Who or what led you to apply to MVCC’s PREP program?
____ It was mailed ___ ACCES-VR ___ Guidance Counselor ___ MVCC Staff/Faculty ___ Other
____ Resource room teacher ____ MVCC Website
Please list any special accommodations (including food allergies) you may require:
The PREP program offers a 1 hour information session from 3-4pm when advocates can learn about
ACCES-VR and ask individualized questions. The session also offers a time to meet Accessibility staff and learn
about disability-related services and accommodations at the college level.
Are you interested in attending this session on the date your student attends the PREP program?
___ Yes ___ No
My signature below indicates that the information in my application is correct, inclusive, and honestly
Signature of Applicant ___________________________________________ Date _______________
click to sign
click to edit
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Emergency Contact Form
Please Print Clearly
Your Name ______________________________________________________________
Address _____________________________________________________________________________
City ______________________________________ State ____________________ Zip ____ ______ ___
Home Phone ( _____ ) _______ - ____________ Date of Birth ____/____/______
Allergies ____________________________________________________________________________
Other Medical Conditions _______________________________________________________________
Please list any medications you take for your allergies/medical conditions _________________________
In the Event of an Emergency, Please Contact
1. Name_____________________________________ Relationship to you ________________________
Day Time Phone (_____)______-_______________ Alternate Phone (_____)______-_______________
2. Name_____________________________________ Relationship to you ________________________
Day Time Phone (_____)______-_______________ Alternate Phone (_____)______-________________
The information requested on this page is confidential and for emergency use only. In the event of a
medical emergency, this information will be used by authorized personnel. Please be honest when
completing all pertinent information.
In the case of an emergency, I give permission for my information to be released by the MVCC Office of
Accessibility to emergency personnel. I also agree that any of my emergency contacts listed on this form
may be notified in an emergency as needed.
Signature of Student ________________________________________ Date ________________
click to sign
click to edit