SPECIAL POPULATIONS SURVEY
PLEASE COMPLETE THIS FORM AND SUBMIT TO THE OFFICE OF ADMISSIONS.
This information is being requested on a voluntary basis and will be kept confidential. Completion of this survey serves as notification to Southern
Crescent Technical College of your special needs under the Americans with Disabilities Act.
Questions concerning Disabilities should be directed to Special Services Office at 770.228.7258, 770.228.7382, or 706.646.6224.
ACADEMIC TERM: ____________________________
NAME: _____________________________________________________ ID # __________________________
CITY: ____________________________________________ STATE: ________________ ZIP: ______________
PHONE #: ______________________________ EMAIL: _____________________________________________
DISADVANTAGED (PLEASE CHECK ALL THAT APPLY)
Individuals with Disabilities
Individuals from Economically Disadvantaged Families, including Low-income Youth and Adults
(Receiving PELL, WIOA, TANF, Vocational Rehabilitation, ETC)
Individuals Preparing for Non-traditional Fields
(A student in a non-traditional program who has chosen to enter training for a field that is dominated by persons of the opposite sex,
such as a male in nursing or a female in automotive technology)
Single Parent, including Single Pregnant Women
(A person who has primary or joint custody of a dependent child. May be divorced, widowed, legally separated, never married, or a
person who is single and pregnant.)
(A person who has not been employed outside of the home, recently suffered loss of income, or recently lost a spouse/partner)
(Primary language is not English or limited ability to write or understand English)
Youth Who Are In or Have Aged out of the Foster Care System
Youth with Parents on Active Duty in the Armed Forces
I have a Vocational Rehabilitation counselor yes no. If yes: Counselor’s name: ____________________________________.
The above is true and correct to the best of my knowledge:
Signature: ___________________________________________________ Date: _______________________
As set forth in full in its Course Catalog/Student Handbook, Southern Crescent Technical College is an Equal Opportunity Institution and does not discriminate on the basis of race, color,
creed, national or ethnic origin, gender, religion, disability, age, political affiliation or belief, genetic information, veteran status or citizenship status (except in those special
circumstances permitted or mandated by law). The following person(s) has been designated to handle inquiries regarding the non-discrimination policies: Title IX/Equity Coordinator
(Griffin Campus, Henry Campus, Butts County Center and the Jasper County Center) Toni Doaty, Griffin Campus, Room 6B, 501 Varsity Road, Griffin, GA 30223, (770)228-7382,
firstname.lastname@example.org; ADA/Section 504 Coordinator (Griffin Campus, Henry Campus, Butts County Center and the Jasper County Center) Teresa Brooks, Griffin Campus, Room 6B, 501
Varsity Road, Griffin, GA 30223, (770)228-7258, email@example.com; Title IX/Equity and ADA/Section 504 Coordinator (Flint River Campus and Taylor County Center) Mary
Jackson, Flint River Campus, Room A-252, 1533 Highway 19 South, Thomaston, GA 30286, (706)646-6224, firstname.lastname@example.org. Any complaints filed against the Title IX/ Equity
Coordinator or ADA/Section 504 Coordinator on any campus/center shall be handled by Xenia Johns, 501 Varsity Road, Griffin, GA 30223, (770)228-7348, email@example.com.
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