Interest Survey
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If you are interested in learning more about becoming a student with Accessible Academics, please fill out the Interest Survey. Our Transition Coordinator will be in touch with you.

Please contact us if you have any questions.

All fields marked with an (*) are required.

CONTACT INFORMATION

First Name(*)
Please enter your first name.

Last Name(*)
Please enter your last name.

Phone Number(*)
Please enter your phone number.

Email(*)
Please enter a valid email address.

I am a(*)

Please select one.

STUDENT INFORMATION

First Name(*)
Please enter the students first name.

Last Name(*)
Please enter the students last name.

Date of Birth(*)
Please enter your date of birth.

Address 1(*)
Please enter your address.

Address 2
Invalid Input

City(*)
Please enter your city.

State(*)
Please enter your state.

Zip Code(*)
Please enter your zip code.

Student’s Current Educational Placement (check all that apply)(*)

Please select one.

High School Year(*)
Please enter the graduation year.

High School Diploma(*)

Please select one.

Associates Year(*)
Please enter the graduation year.

Associates Degree(*)
Please enter the Associates degree.

Bachelor’s Year(*)
Please enter the graduation year.

Bachelor’s Degree(*)
Please enter the Bachelor’s degree.

Student’s Current Employment Status (check all that apply)(*)

Please select one.

Current Income/Benefits (check all that apply)(*)

Please select one.

Annual Household Income(*)
Please enter your annual household income.

Student is Interested In (check all that apply)(*)

Please select one.

Please Estimate Anticipated Enrollment in Accessible Academics(*)

Please select one.

Anticipated Enrollment Year(*)
Please enter the anticipated enrollment year.

Please take a moment to describe what areas you feel you need assistance with pertaining to school (i.e., time management, organization, subject specific tutoring)(*)
Please tell us what areas you feel you need assistance with pertaining to school.

Please describe what areas you feel you need assistance with pertaining to Life Skills (i.e., cleaning, laundry, food prep, shopping, budgeting, socialization, public safety, etc.)(*)
Please tell us what areas you feel you need assistance with pertaining to life skills.

Please describe what areas you feel you need assistance with pertaining to Career Attainment (i.e.,resume building, interviewing skills, finding employment, maintaining employment)(*)
Please tell us what areas you feel you need assistance with pertaining to career attainment.

ADDITIONAL INFORMATION

How did you hear about us?(*)

Please select one.

Questions / Comments
Please enter your questions or comments.

Human Verify(*)
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Contact Us

Phone: 1-716-492-8656

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Hours of Operation

Monday - Friday | 9 AM to 5 PM
Saturday & Sunday | By Appt. Only

Accessible Academics | Making Independence Accessible