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.

Address 1(*)
Please enter your address.

Address 2
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City(*)
Please enter your city.

State(*)
Please enter your state.

Zip Code(*)
Please enter your zip code.

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.

Student Age
Please enter your date of birth.

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.

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

Please select one.

Semester and year of anticipated enrollment
Please enter the anticipated enrollment year.

Please describe what areas of support you are interested in learning more about (academic, life skills, social, vocational)(*)
Please tell us what areas of support you are interested in.

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