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Student Accessibility Services Intake Form
Please fill out the information below to register with NCKTC Student Accessibility Services and begin the process for requesting support services.
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* Indicates required question
Email
*
Your email
Full Name:
*
Your answer
Address:
Your answer
City, State, Zip:
Your answer
Phone:
*
Your answer
Which is the best way to contact you?
Email
Phone
Text
Other:
Date of birth:
MM
/
DD
/
YYYY
NCK Tech Program:
*
Your answer
Campus Location
*
Beloit
Hays
Required
How did you hear about us?
ADA statement on course syllabus
Another student
College Instructor
College Staff
College catalog/materials
High School
Parent
Vocational Rehabilitation Services
Website
Other:
Are you a client of Vocational Rehabilitation Services (VR)?
Yes
No
Maybe
Clear selection
If you answered "yes" to the previous question, please provide your case manager's name and contact information.
Your answer
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