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Academy for Inclusive Learning and Social Growth Application

The recommended browser to submit this form is Google Chrome. Other browsers are unsupported and may cause submission errors.

Student Information

Term and Year

First Name

Middle Name

Last Name

Gender

FemaleMale

Cell Phone

Home Phone

Email Address

This email address is vital for accessing a partially complete application and receiving confirmation once you have submitted a complete application. While this is under the student’s information, the email address does not necessarily need to be the student’s.

Street Address

City

State

Zip Code

Date of Birth:

Age

Are you a U.S Citizen?:

YesNo

Native Language

Do you receive support services from: (Please check all that apply)

Please specify other services received

Are you currently active on Vocational Rehabilitation caseload?

YesNo

How did you hear about the Academy of Inclusive Learning and Social Growth?

High School Guidance CounselorTransition FairCommunity Service Agency (e.g. Georgia Council on Developmental Disabilities)Previous or Current Academy StudentOther

Please specify

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Transportation Information

What is your form of transportation? (Please check all that apply)

Please specify:

Are there any limitations, support needs, or related issues to transportation?

YesNo

Please List:

Note: Kennesaw State University Academy for Inclusive Learning is unable to provide transportation to and from campus.

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Medical Information

Please give a brief description of your medical history including any disability diagnoses that you may have:

Please list any significant medical or physical conditions that may affect your participation in classroom, social, or recreational activities on campus:

Please list any current medications and indicate for what the medications are taken:

Please list all allergies and if you carry an EpiPen:

Note: If the applicant must take medications while on campus, he/she must be independent in administering his/her medications. Kennesaw State University Academy for Inclusive Learning does not have the personnel or facility to administer medications. This capability is not included in any of the program or college services.

Do you currently receive private therapeutic services, such as physical therapy, occupational therapy, psychiatric therapy, behavioral therapy, speech therapy?

YesNo

Are you independent in activities of daily living (ADL), i.e. bathroom activities?

YesNo

Do you have any physical and/or emotional limitations?

YesNo

Please list any physical and/or emotional limitations

Note: If needed, the applicant will need to arrange for personal assistance services in order to attend the Academy for Inclusive Learning program. This is not included in any of the program or college services. Limitations do not deny admission.

Please provide any other medical information that you feel would be important regarding your participation in this program:

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Please submit the following required documents.

Unofficial Transcript

Unofficial Transcript

Please attach only .doc, .pdf or similar files. No .jpeg or image files will be accepted.

Psychological Evaluation

Psychological evaluations cannot be more than 24 months old at the time of application review.

Psychological Evaluation

Please attach only .doc, .pdf or similar files. No .jpeg or image files will be accepted.

IEP (or similar document)

IEP (or similar document)

Please attach only .doc, .pdf or similar files. No .jpeg or image files will be accepted.

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Acknowledgement

Release

Release and Exchange of Information Form

Kennesaw State University treats and regards all written documentation obtained to verify a disability and plan for appropriate services as well as all documented services and contracts with the Office of Vocational Rehabilitation as confidential. However, it may be necessary for our staff to exchange some information about you with the Kennesaw State faculty and staff, as well as outside agencies, in order to complete the student evaluation process for admissions. This exchange will occur only with your written permission, as given in this document below, and with the understanding that only information necessary for the purposes of obtaining the applicable information to complete the admissions process.

I give permission to exchange information about me to the following offices/individuals checked below:

Please specify

Waiver

I agree, as part of the application process, to waive my right to access the completed student recommendation form

Agreement

Application Agreement

I certify that the responses provided on my application are true and complete to the best of my knowledge, pursuant to reasonable inquiry where needed. I understand my failure to provide complete, accurate, and truthful information on this application will be grounds to deny or withdraw my admission, or dismiss me after enrollment. I acknowledge that I will not be considered for admission until I have submitted all credentials. I also agree to inform the Academy for Inclusive Learning and Social Growth of any change in my plans to participate in the Academy for Inclusive Learning and Social Growth, or change residency.

Signature

Please type your full name.

Date

The Academy for Inclusive Learning and Social Growth will reach out to you within 3-5 business days upon receipt. An email will be sent to your email once the submission has been reviewed.

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Academy for Inclusive Learning and Social Growth Application

The recommended browser to submit this form is Google Chrome. Other browsers are unsupported and may cause submission errors.

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Please submit the following required documents.

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