Special Populations Classification Form

1Personal Info

2Student Info

3Special Populations

4Disability Services

Personal Information

Name*

First Middle Last

Preferred Name

Address

Street Address Address Line 2 City State ZIP Code

Student Email*

Your Lanier Technical College Student Email address. ex: jdoe@student.laniertech.edu

Enter Email Confirm Email

Alternate Email

Your alternate or personal email address, if you would like to provide one. ex: gmail, yahoo, outlook, etc.

Enter Email Confirm Email

Phone*

Last four digits of your Social Security #

Student Information

Student ID #*

Semester of Enrollment

Fall

Spring

Summer

Campus

Hall

Barrow

Dawson

Forsyth

Jackson

Dual Enrollment Site

Program Major

Program Award Level

Certificate

Diploma

Degree

Special Populations Classification

Check all that apply.

I am a person who has the primary or joint custody for a dependent child. You may be divorced, widowed, legally separated, never married or a person who is single and pregnant.

I have been financially supported by another family member in the past and that financial support no longer exists.

I am unemployed or underemployed and having difficulty obtaining or upgrading employment.

I have custody of one or more children with less than two years remaining to receive Title IV Social Security assistance.

I am a person with a disability. Anyone with a physical or mental impairment that substantially limits one or more major life activities, such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.

English is NOT my first language. I have difficulty speaking, understanding, reading, or writing English.

English is NOT my first language. I do NOT have difficulty speaking, understanding, reading, or writing English.

None of the above special populations categories applies to me.

Contact Kari Register, Special Populations Coordinator, for assistance with barriers to college not related to disability. 770-533-7005 or kregister@laniertech.edu
Contact Tina Schnepper, Lead ESL Instructor, for assistance with learning English. 770-531-3353 or tschnep@laniertech.edu

Disability Services Classification

Check all that apply.

Specific Learning Disability (dyslexia, perceptual impairments, math or reading comprehension)

Attention Deficit Hyperactivity Disorder (ADHD)

Hearing Impairment (severe and/or either permanent or fluctuation)

Deafness (impaired processing of language through hearing)

Speech or Language Impairment (stuttering or language or voice impairment)

Deaf-Blindness (hearing and visual impairments)

Visual Impairment (severely visually impaired impaired or blind persons)

Emotional Disturbance (depression, fears, or unsatisfactory interpersonal relationships, schizophrenia)

Orthopedic Impairment (absence of finger, toe or limb, arthritis, cerebral palsy, debilitating condition)

Other Health Impairments (chronic or acute heart condition, asthma, sickle cell anemia, hemophilia, epilepsy, leukemia, or diabetes)

Traumatic Brain Injury (external or internal injury to the brain)

Autism

Special Services/Accommodations*

My condition may require special services/accommodations to complete my program of study.

My condition should NOT require special services to complete my program of study.

Contact Allison Haynes, Coordinator of Disability Services, for classroom accommodations (must be medically documented) 770-533-7003 or vbowermaster@laniertech.edu

As set forth in its student catalog, Lanier Technical College does not discriminate on basis of race, color, creed, national or ethnic origin, gender, religion, disability, age, political affiliation or belief, veteran status, or citizenship status (except in those special circumstances permitted or mandated by law).

Title IX Coordinator: Nancy Beaver, 2535 Lanier Tech Dr, Gainesville, GA 30507, Breeden-Giles, 1131 G, Ph: 770-533-7001 or Email: nbeaver@laniertech.edu

Section 504/ADA Coordinator: Veronica Bowermaster, 2535 Lanier Tech Dr, Gainesville, GA 30507, Breeden-Giles, 1130, Ph: 770-533-7003 or Email: vbowermaster@laniertech.edu

Signature*

Date*

MM slash DD slash YYYY

Comments

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