Online Student Application

1. Start Term *: Select One 2021 - Fall 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Spring 2035 - Summer 2035 - Fall
   Note: Select when you would like to start your services.
2. Primary Campus *: Select One Dayton Campus (Dayton, Ohio) Lake Campus (Celina, Ohio)
   Note: Please select campus location where you will be enrolled.
3. Expected Graduation Term: Select One 2011 - PRE 2011 - Spring 2011 - Summer 2011 - Fall 2012 - Spring 2012 - Summer 2012 - Fall 2013 - Spring 2013 - Summer 2013 - Fall 2014 - Spring 2014 - Summer 2014 - Fall 2015 - Spring 2015 - Summer 2015 - Fall 2016 - Spring 2016 - Summer 2016 - Fall 2017 - Spring 2017 - Summer 2017 - Fall 2018 - Spring 2018 - Summer 2018 - Fall 2019 - Spring 2019 - Summer 2019 - Fall 2020 - Spring 2020 - Summer 2020 - Fall 2021 - Spring 2021 - Summer 2021 - Fall 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall 2034 - Spring 2034 - Summer 2034 - Fall 2035 - Spring 2035 - Summer 2035 - Fall
   Note: Select when you plan to graduate.
4. First Name *:
5. Last Name *:
6. Middle Name:
7. Optional: Preferred Name:
8. Student ID:
   Hint: Enter 9 alpha numeric characters.
9. Birth Date:
   Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
10. Gender *: Select One Female Male Non-Binary Not Specified Transgender
11. Pronouns: Select One He/Him/His She/Her/Hers They/Them/Theirs

1. Primary Phone Number:
   Hint: Enter 10-digit number only.
2. Secondary Phone Number:
   Hint: Enter 10-digit number only.
3. Email Address *:

1. Address *:
2. City *:
3. State *: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode *:
   Hint: Enter zipcode as 97331 or 97331-0000.

Same as Local Address

1. Address:
2. City:
3. State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode:
   Hint: Enter zipcode as 97331 or 97331-0000.

1. Seeking Degree: Select One Certificate Doctorate of Psychology Graduate Degree Medical Degree Undergraduate Degree
2. Major: Select One Accountancy Acting African & African American Studies Anthropology Art History Art Studio Athletic Training Biological Sciences Biomedical Engineering Business Economics Career, Technical & Adult Education Chemistry Classical Humanities Clinical Laboratory Science Communication Studies Community Health Education Computer Engineering Computer Science Crime and Justice Studies Dance Design/Technology-Theatre Early Childhood Education Earth & Environmental Science Economics Electrical Engineering English Finance Financial Services French Geography German Greek History Human Resource Management Industrial & Systems Engineering International Business International Studies Latin Liberal Studies Management Management Information Systems Marketing Mass Communication Materials Science & Engineering Mathematics Mechanical Engineering Middle Childhood Education Motion Pictures Music Music Education Music History and Literature Music Performance Nursing Organizational Leadership Philosophy Physical Education Physics Political Science Pre-Professional Programs Psychology Rehabilitation Services Religion Selected Studies Sign Language Interpreter Social Science Education Social Work Sociology Spanish Sports Science Statistics Studio Art Supply Chain Management Theatre Studies Undecided Urban Affairs Women's Studies

Affiliation(s)

3. Affiliation(s)

   Boonshoft School of Medicine

   Clark State Gateway Program

   College Credit Plus

   Graduate School

   Military- Active Duty or Reserve

   Military- Service Connected Disability

   Military- Veteran

   School of Professional Psychology

   Sinclair Wright Path Program

   SOCHE Consortium

   State Vocational Rehabilitation (OOD, BVR, BSVI, etc.)

Ethnicity(ies)

4. Ethnicity(ies)

   American Indian/Alaskan Native

   Asian

   Black or African-American

   Hispanic or Latino

   Native Hawaiian or Pacific Islander

   White
5. Additional Note:

1. Where did you attend high school? Please provide name of school and location. *
2. In high school, did you have any of the following? (Check all that apply.) If you had any of these in high school, please send our office the most recent copy.

   IEP

   504 Plan

   ETR

   MFE

   Additional Note or Comment
3. Have you ever attended another college or university? If yes, please list institution name and location. *

   Yes

   No

   Additional Note or Comment
4. Did you receive accommodations from your previous institution(s)? If yes, please submit a letter from your previous institution(s) describing the accommodations you received. *

   Yes

   No

   Additional Note or Comment
5. Admission to Wright State University is separate from applying for services from our office. Have you applied to the university for admission? *

   Yes

   No

   Additional Note or Comment
6. What is the nature of your disability. Please choose all that apply to you:

   ADD/ADHD

   Aspergers/Autism Spectrum Disorder

   Hearing Impairments

   Learning Disability

   Other (multiple disability, deaf/blind)

   Other Health Impaired

   Physical Disability

   Psychological/Mental Health

   Speech/Language Impairment

   Traumatic Brain Injury

   Visual Impairments/Blindness

   Additional Note or Comment
7. Using your own words, please describe your disability(ies) and how it affects your ability to function in an academic setting. *
8. If applicable, please list any adaptive/computer technologies that you will be requesting or using. *
9. Please list any additional academic accommodations and services you are requesting. *
10. I understand that in order to finalize my eligibility for ODS services/accommodations, I am responsible for submitting documentation of my disability(ies) prior to meeting with an ODS counselor for my pre-service interview. I also understand that the application for Disability Services is independent from my application for admission to Wright State University. Mark YES for electronic signature. *

    Yes

    No

    Additional Note or Comment