CNM DRC Student Information Form First Name: Last Name: MI: Date of Birth: Are you under the age of 18? Yes No CNM ID#: CNM Email: Contact Email: Phone (Cell) Number: Second Phone Number: Do you have a disability? Yes No Do you have disability-related documentation with you today? Yes No (such as an IEP, Medical documentation or Social Security award document) Are you eligible for the Bridge Scholarship Yes No Lottery Scholarship Yes No In your own words, describe your disability: Are you receiving services from any other adult service provider for individuals with disabilities? Check all that apply Adult Disability Service Providers Independent Living Commission for the Blind Social Security Beneficiary Developmental Disability Waiver Disability Veteran’s Administration Division of Vocational Rehabilitation Other Service Provider Did you graduate high school? Yes No Do you have a GED? Yes No If no, highest grade completed and year exited high school: Grade Year Were you in Special Education? Yes No Did you have a 504 Plan? Yes No If yes, what services did you receive? Have you attended or graduated from a college or university? Yes No Are you currently transferring from or co-enrolled in another college or university? Yes No Have you received accommodations from a previous college or university? Yes No If yes, what accommodations did you receive? Are you a veteran? Yes No Office Use Only Date completed by Academic Coach: ____/____/____ SGADISA Banner entry _____ Yes No Deaf student? Accommodate entry verified: _____   Student Database entry _____ STATUS TERM YEAR ACHIEVEMENT COACH  Fall 2017 101: HOP New    Reactivate Spring 2018 102: LEI     Inactivate/ Archive Summer 2019 103: OKE     Transfer Case 2020 104: SAN   FROM _______  105: JIR TO _______
CNM DRC Student Information Form First Name: Last Name: MI: Date of Birth: Are you under the age of 18? Yes No CNM ID#: CNM Email: Contact Email: Phone (Cell) Number: Second Phone Number: Do you have a disability? Yes No Do you have disability-related documentation with you today? Yes No (such as an IEP, Medical documentation or Social Security award document) Are you eligible for the Bridge Scholarship Yes No Lottery Scholarship Yes No In your own words, describe your disability: Are you receiving services from any other adult service provider for individuals with disabilities? Check all that apply Adult Disability Service Providers Independent Living Commission for the Blind Social Security Beneficiary Developmental Disability Waiver Disability Veteran’s Administration Division of Vocational Rehabilitation Other Service Provider Did you graduate high school? Yes No Do you have a GED? Yes No If no, highest grade completed and year exited high school: Grade Year Were you in Special Education? Yes No Did you have a 504 Plan? Yes No If yes, what services did you receive? Have you attended or graduated from a college or university? Yes No Are you currently transferring from or co-enrolled in another college or university? Yes No Have you received accommodations from a previous college or university? Yes No If yes, what accommodations did you receive? Are you a veteran? Yes No Office Use Only Date completed by Academic Coach: ____/____/____ SGADISA Banner entry _____ Deaf student? Yes  No  Accommodate entry verified: _____ Student Database entry _____ STATUS TERM YEAR ACHIEVEMENT COACH New  Fall  2017  101: HOP  Reactivate  Spring  2018  102: LEI  Inactivate/ Archive  Summer  2019  103: OKE  Transfer Case  2020  104: SAN FROM _______  105: JIR TO _______
copy_of_student-information-form-new-fillable.docx