Disability Services Classification Form 1Personal Info2Student Info3Special Populations4Disability Services Personal InformationName* First Middle Last Preferred Name Address Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Student Email*Your Lanier Technical College Student Email address. ex: jdoe@student.laniertech.edu Enter Email Confirm Email Alternate EmailYour 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 InformationStudent ID #* Semester of Enrollment Fall Spring Summer Campus Hall Barrow Dawson Forsyth Jackson Dual Enrollment Site Program Major--Select One--AccountingAir Conditioning TechnologyAssociate of Science in NursingAutomotive Collision RepairAutomotive TechnologyBuilding Automation SystemsBusiness ManagementBusiness TechnologyComputer Information SystemsConstruction Management Technology & CarpentryCosmetologyCriminal Justice TechnologyCulinary ArtsDental AssistingDental HygieneDesign and Media Production TechnologyDiesel Equipment TechnologyDrafting TechnologyEarly Childhood Care and EducationElectrical Systems TechnologyElectrical Utility TechnologyEmergency ManagementEngineering TechnologyEstheticianFire Science TechnologyHealth Information Management TechnologyHealthcare AssistantHorticultureIndustrial Systems TechnologyInterdisciplinary StudiesInteriorsLogisticsMarine Engine TechnologyMechatronics TechnologyMedical AssistingMotorsports Vehicle TechnologyNurse AideParamedicinePharmacy TechnologyPhlebotomy TechnicianPhysical Therapist AssistantPractical NursingPrecision Machining and ManufacturingRadiologic TechnologySurgical TechnologyTechnical SpecialistWelding and Joining TechnologyWireless Engineering TechnologyOther/UnsureProgram Award Level Certificate Diploma Degree Special Populations ClassificationSpecial Populations ClassificationCheck all that apply. 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. 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. Anyone with a physical or mental impairment that substantially limits one or more major life activities. 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 ClassificationDisability Services ClassificationCheck 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 ahaynes@laniertech.eduAs 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.eduSignature*Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged. Tags:Disability ServicesSpecial PopulationsStudent Affairs