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Online Student Application
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Personal Information
First Name
*
:
Last Name
*
:
Optional: Preferred Name:
Student ID:
Hint: if you do not have a USU A-number leave blank.
Birth Date:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Gender
*
:
Select One
Female
Male
Nonbinary/Genderqueer
Not Specified
Prefer Not to Disclose
Pronouns
*
:
Select One
he/him
he/they
she/her
she/they
they/them
Contact Information
Phone Number:
Hint: Enter 10-digit number only.
Email Address
*
:
Hint: Enter your @usu.edu Email Address if you have one.
Address
Address
*
:
City
*
:
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
Zipcode
*
:
Hint: Enter zipcode as 97331 or 97331-0000.
Questions
High School GPA
*
(Required)
List your ACT/SAT Score or answer none if you do not know your score.
*
(Required)
Class
*
(Selection is Required)
Freshman
Sophomore
Junior
Senior
Masters Degree
Doctoral Degree
Additional Note or Comment
Major
*
(Required)
Where do you attend classes? (Logan, Brigham City, Online, Etc.)
*
(Required)
How did you learn about the Disability Resource Center?
*
(Selection is Required)
Instructor
Advisor
Employer
Parent
Spouse
Friend
Online
Other
Additional Note or Comment
Have you been diagnosed with a disability? If yes, please list the year you were diagnosed and describe your disability.
*
(Required)
Are you currently taking any medications? If yes, please list them. (ESA Applicants should enter N/A)
*
(Required)
Have you used accommodations in the past? If yes, please describe them.
*
(Required)
What academic challenges or barriers are you facing?
*
(Required)
What accommodations or services do you feel will be helpful to you?
*
(Required)
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