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Primary Campus
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Cascade
Distance Learning
Newberg
Rock Creek
Southeast
Sylvania
First Name
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Last Name
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Middle Name:
Nick Name:
PCC G Number:
Hint: G01234567
Birth Date:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Contact Information
Cell Phone Number:
Hint: Enter 10-digit number only.
Land Line Phone Number:
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Email Address
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Note: If you already have PCC email address, please provide one.
Additional Information
Start Term
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2024 - Spring
2024 - Summer
2024 - Fall
2025 - Winter
2025 - Spring
2025 - Summer
2025 - Fall
Note: Select when you would like to start your disability services.
Expected Graduation Term:
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2008 - Winter
2008 - Spring
2008 - Summer
2008 - Fall
2009 - Winter
2009 - Spring
2009 - Summer
2009 - Fall
2010 - Winter
2010 - Spring
2010 - Summer
2010 - Fall
2011 - Winter
2011 - Spring
2011 - Summer
2011 - Fall
2012 - Winter
2012 - Spring
2012 - Summer
2012 - Fall
2013 - Winter
2013 - Spring
2013 - Summer
2013 - Fall
2014 - Winter
2014 - Spring
2014 - Summer
2014 - Fall
2015 - Winter
2015 - Spring
2015 - Summer
2015 - Fall
2016 - Winter
2016 - Spring
2016 - Summer
2016 - Fall
2017 - Winter
2017 - Spring
2017 - Summer
2017 - Fall
2018 - Winter
2018 - Spring
2018 - Summer
2018 - Fall
2019 - Winter
2019 - Spring
2019 - Summer
2019 - Fall
2020 - Winter
2020 - Spring
2020 - Summer
2020 - Fall
2021 - Winter
2021 - Spring
2021 - Summer
2021 - Fall
2022 - Winter
2022 - Spring
2022 - Summer
2022 - Fall
2023 - Winter
2023 - Spring
2023 - Summer
2023 - Fall
2024 - Winter
2024 - Spring
2024 - Summer
2024 - Fall
2025 - Winter
2025 - Spring
2025 - Summer
2025 - Fall
Note: Select when you plan to graduate.
Additional Note:
Questions
What brings you to Disability Services
I am looking for information - I want to know what my options are
I am looking for accommodation - I need adjustments to engage in my studies
Other (Specify Below)
Additional Note or Comment
Were you referred by someone?
Yes, If yes, by whom? (Specify Below)
No
Additional Note or Comment
Did you graduate from high school?
*
(Selection is Required)
Yes If yes please provide the year and whether it was a STANDARD Diploma or a MODIFIED Diploma (Specify Below)
No
Additional Note or Comment
Did you complete a GED?
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(Selection is Required)
Yes, specify year you completed GED (Specify Below)
No
Additional Note or Comment
Have you used accommodations in the past?
No
Yes, in K-12 through an IEP or 504 Plan
Yes, in a College or University setting
Yes, through Employment
Other (Specify Below)
Additional Note or Comment
FUNCTIONAL LIMITATIONS: I have difficulty or may need assistance with:
Seeing: printed materials, overheads, chalk/whiteboard, program access, other
Hearing: lectures, group discussions, speaking, other
Learning: taking notes, In-class assignments, other
Understanding: textbooks, lectures, discussions, handouts, graphs/charts
Testing: completing on time, easily distracted, other
Physical Activities: Sitting, stairs, manipulating objects, manual task, other
Participation: Attending class regularly, focus/concentration, groups, other
Communicating: with instructor, other
Additional Note or Comment
How do you rate your own self-advocacy skills
I'm not sure what self-advocacy skills are
I frequently have difficulty advocating for myself
I am usually comfortable advocating for myself
Comments (Specify Below)
Additional Note or Comment
What is your understanding of how the accommodation process works? There are no wrong answers here.
If you need accommodation for the information session or initial appointment, please specify below
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