Special Populations Classification Form 1Personal Info2Student Info3Special Populations NameThis field is for validation purposes and should be left unchanged.Personal InformationName* First Middle Last Preferred NameEnter your preferred name here if you use a name different from above.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 This field is hidden when viewing the formAlternate EmailYour alternate or personal email address, if you would like to provide one. ex: gmail, yahoo, outlook, etc. Enter Email Confirm Email Phone*This field is hidden when viewing the formLast four digits of your Social Security # Student InformationStudent ID #*Your 9-digit Lanier Tech Student 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, Coordinator of Special Populations, 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.eduSignature*Date* MM slash DD slash YYYY Tags:Special PopulationsStudent Affairs