Lehman College / CUNY- (SDS) Application Form EMPL ID: Date: / / Section 1: Personal Information Date of Birth: / / SS#: - - Name: First M. Last Gender: Male Female Email address: Alternative Email address: Apartment #: Address: Zip Code: State: City: Cell Phone Number: Home Number: Emergency Phone Number: - - - - - - Preferred contact method: Phone Call E-mail Mail How do you travel to campus: Access - A- Ride Bus/Subway Car Walk Rail/Train Are you registered to vote? Yes No (Please see last page.) Have you ever been enlisted in any branch of the US military (active duty, veteran, national guard or reserve)? Yes No Are you a dependent of a veteran? Yes No Did your military experiences include traumatic or highly stressful experiences which continue to affect you? Yes No If yes, please describe below: Who referred you to our office? A) Self I) Office of SDS at another College B) Friend J) Dean C) Family K) SEEK D) Faculty or Mentor L) FYI seminar E) Career Services M) High School Advisor F) Campus Life N) Academic Advisement G) Student Health Center O) Veterans H) Counseling Center P) Other... Page 1 of 7 Revised: A.B. – 08/17/2015 Section 2: Disability-Related Information Do you have a diagnosed and documented disability? Yes No Do you have multiple disabilities? Yes No If yes, please check all that apply: ORTHOPEDIC Wheelchair User Other Assistive Devices ( Braces, Crutches, Cane, Prosthesis) Other Orthopedic ( No Devices) Other Mobility Limitation ( Includes Asthma, Heart, kidney, CP, Spinal Surgery) Hand Dysfunction VISUAL Totally Blind Legally Blind Visually Impaired ( NOT legally blind) HEARING Deaf Hard of Hearing Speech Psychological Substances Abuse Learning Disability Asperger’s or Autism ADD or ADHD Traumatic Brain Injury (TBI) Temporary Other Medical Please, specify if not listed above: Do you have a medical doctor or physician? Yes No Name: Phone: Do you have a therapist/psychiatrist? Yes No Name: Phone: Are you currently taking any medications to treat any disability or medical condition indicated above? Page 2 of 7 Section 3: DEMOGRAPHICS Note: This information is being requested for statistical and grant/scholarship purposes only. Race/Ethnicity (PLEASE CHECK): African American/Black Native Hawaiian or Pacific Islander American Indian /Alaskan Native Multiracial Caucasian /White Prefer not to answer Hispanic/Latino-a Other Is either your mother or your father a college graduate? Yes No If yes, do your parents have a: AA BA MA Higher degree Are you a: U.S. citizen? Yes No -or- Legal Resident? Yes No Are you an international student? Yes No If you were born outside of the U.S. please indicate where: What is your first language? Section 4: ENROLLMENT STATUS Are you an/a: Undergraduate Graduate If you are a GRADUATE student skip to Page 4, Section 6. Section 5: ACADEMIC INFORMATION: for Undergraduate students only Current Academic Status: Freshman (0 – 30 credits) 2nd Degree Sophomore (31 - 60 credits) Non-Matriculate Junior (61 – 90 credits) H.S. student taking college classes Senior (91 – or more credits) Registration status: Full time (12+ credits) Non-matriculated Part-time (Under 12 credits) Continuing Education Are you currently on Academic Probation? Yes No Have you ever been dismissed from Lehman? Yes No Are you a transfer student? Yes No If you are a transfer student, where did you transfer from? If you are a transfer student, did you receive accommodations at your former institution? Yes No Page 3 of 7 If yes, what accommodations did you receive? Please describe below: What is your current GPA? Number of credits completed: Which type of degree are you currently pursuing? B.A. B.S. B.F.A B.A. /M.A. Certifícate Program Major: Check box if undecided on the major: Are you connected to any of these special campus programs? The Adult Degree Program Individualized Bachelor of Arts Teacher Academy (Trio Grant) Second Undergraduate Degree Program The Lehman Scholars program Urban Male Leadership Program CUNY Baccalaureate Macaulay Honors College Interdisciplinary and Interdepartmental Programs College Now Program Lehman Center for Students Leadership Development Other: Section 6: ACADEMIC INFORMATION: for Graduate students only Note: If you’re a Graduate student please complete this section. Which type of degree are you currently pursuing? Master of Arts (M.A.) Master of Fine Arts (M.F.A.) Master of Science (M.S.) Master of Public Health (M.P.H.) Master of Science in Education (M.S.Ed.) Master of Social Work (M.S.W.) Master of Arts in Teaching (M.A.T.) Doctoral Degree (Ph.D.) Area of study: Other graduate or professional degree type, please describe: What is your current GPA? Number of credits completed: Section 7: ASSISTIVE TECHNOLOGY and ALTERNATIVE TEXTBOOKS What assistive technology software do you use? (Please check all that apply. If none, please skip to next section.) None Kurzweil 1000 Read & Write Gold Kurzweil 3000 JAWS Dragon NaturallySpeaking ZoomText Other Page 4 of 7 What assistive technology hardware do you use? (Please check all that apply.) CCTV Tape Recorder Victor Reader Large Print Keyboard Handheld Magnifier Livescribe Smartpen Handheld/Portable CCTV None What are your preferred alternate textbook formats? (Please check all that apply.) Microsoft Word (E-text) Adobe Acrobat PDF (E-text) Learning Ally (DAISY Audio) Large print Section 8: AGENCY INFORMATION Sponsorship (check all that apply): ACCES-VR CBVH SEEK VA Other Are you a CUNY LEADS Student? Yes No LEADS counselor’s name: Number: ACCES-VR counselor’s name: Number: CBVH counselor’s name: Number: SEEK counselor’s name: Number: Section 9: FINANCIAL INFORMATION Have you completed the FAFSA application for the current year? Yes No Have you completed the TAP application for the current year? Yes No Are you receiving any of the following: Social Security Disability (SSDI) Social Security Insurance (SSI) Veteran’s Benefits If yes, how much do you receive monthly: How do you plan to pay for your tuition/books? (Check all that apply.) Pell–Federal Veterans TAP Social Security Loan Employer/1199 ACCES-VR Do not know CBVH Other, please explain: Page 5 of 7 Section 10: LIFESTYLE/SUPPORT NETWORK Please estimate the number of hours per week you are actively involved in organized extra-curricular activity (e.g., sports, clubs, student government, etc.): If any, please describe the activity in the space provided below: What is the average number of hours you work per week during the school year (Paid employment only)? How would you describe your financial situation right now? Always stressful Often stressful Sometimes stressful Rarely stressful Never stressful Where do you currently reside? Lehman Residence Hall/Apartment Off campus apartment/House Other (please specify): With whom do you currently live? Alone Spouse, partner, or significant other Roommate (s) Family other (i.e. mother, father, sister, EST.) Other (please specify): Is there anything else you would like to tell us? Please use the space below: PLEASE PRINT & SIGN YOUR NAME PRINT SIGN DATE Page 6 of 7 Test-Taking . Multiple Choice . Essay . Reading Questions . Writing Out Answers . Finishing On Time In Classes . Course Attendance . Note-taking . Listening/Focus . Speaking Class Assignments . Papers . Presentations . Group Projects . Lab Projects Homework . Reading/ Comprehension . Writing/Typing . Research . Short-term Memory Under Time Constraints . Time Management . Short-term Deadlines . Long-term Deadlines . Feeling Anxious Online . Reading Online Content . Viewing Videos . Participating In Chats . General Accessibility Other . Housing . Social Interactions . Computer Use . Campus Community Courses Most Challenging . Math . Reading . Writing . Science . Foreign Language Other Comments Or Campus Barriers Not Yet Mentioned? (Optional) Technology You Own? (Check All) . PC . PC Laptop . Mac . Mac Laptop . iPhone . iPad . Android Phone . Android Tablet . Dragon . Kurzweil . Smart Pen . Audio Recorder . Other: ________________________________ Are you interested in learning about apps or other technology that may help you . Yes . No If yes, please specify: in your academic work? Student Disability Services Shuster Hall Room 238 disability.services@lehman.cuny.edu (718) 960-8441 What’s Your Experience? Name: Date: Please check the following areas where you feel you experience the most significant barriers/challenges to achieving your academic goals? This initial information will assist our staff in guiding the conversation. Page 7 of 7