Fillable PREP Application (Mohawk Valley Community College)

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PREP Application (Mohawk Valley Community College)

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The PREP Application (Mohawk Valley Community College) form is 4 pages long and contains:

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  • 35 check-boxes
  • 77 other fields

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File type: PDF

U.S.A. forms for Mohawk Valley Community College

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Please fill out the application below 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:
Mail
Mohawk Valley Community College
Office of Accessibility Resources
1101 Sherman Drive
Utica, NY 13501
Fax
315-731-5868
Email
oar@mvcc.edu
Online
https://www.mvcc.edu/accessibility-resources/PREP
MVCC 2019 PREP Program Application
I plan to attend the program on (check ONE you plan to attend)
Name ________________________________________ Preferred Name ________________________
First Last
Address ______________________________ City _____________ State ______ Zip _____________
County ________________________
Home Phone ( _______ ) ________ - ___________ Cell 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 2019 ____ Spring 2020
Do you plan to live on campus? ____Yes ____ No Do you work with ACCES-VR? ____ 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
1.
City & State
Date of Attendance
(from-to) Month/Year
Date or Expected Date
of Graduation
2.
3.
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
Choose One
Have you ever attended college? ____ Yes ____ No If yes, where/when?_____________________
Did you receive accommodative services? ___Yes ___ No If yes, what were they? _____________
____________________________________________________________________________________
____________________________________________________________________________________
What academic courses do you find most difficult? ________________________________________
____________________________________________________________________________________
What aspect of school challenges you the most?
___ Studying
___ Reading
___ Test taking
___ Focusing
___ Socializing/Communicating
___ Staying Organized
___ Time management
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?
Please list any special accommodations (including food allergies) you may require:
____________________________________________________________________________________
Parents/Guardians/Advocates
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.
___ Yes ___ No
My signature below indicates that the information in my application is correct, inclusive, and honestly
presented.
Signature of Applicant ___________________________________________ Date _______________
Choose One
Emergency Contact Form
Your Name ______________________________________________________________
Address _____________________________________________________________________________
Ci
ty ______________________________________ 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 ________________________
Address ______________________________________________________________________________
Day Time Phone (_____)______-_______________ Alternate Phone (_____)______-________________
2. Name_____________________________________ Relationship to you ________________________
Address ______________________________________________________________________________
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 ________________
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PREP Application (Mohawk Valley Community College)

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Completed 26 July 2020

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