OAI Application for Services

Northland Pioneer College embraces both the letter and the spirit of the Americans with Disabilities Act, its amendments and Section 504 of the Rehabilitation Act. The purpose of these laws is to create an environment of equal access for students with disabilities.

By submitting this form, you are providing this information to Northland Pioneer College's Office of Accessibility and Inclusion Coordinator, and grant permission for the coordinator to contact you.

If you need help completing this application, please ask for assistance.

Questions Contact Catherine (Kate) Buckhorn Office of Accessibility and Inclusion, Interim Coordinator, at (928) 536-6246 | FAX: (928) 532-6199 | email

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Disability Services
Complete

Personal Information

NPC Student ID Number

Please enter your NPC Student Identification Number.
If you do not currently have an NPC ID number, take two forms of ID, one with a photo, to the front office of your local campus or center.

Name

Your Full Name

Email: The best email address at which to reach you.

*Please provide your NPC email address (if you have one)

Phone: Phone number that we can contact you at.

Date of Birth

Please enter your date of birth in the format Month-Date-Year.

Emergency/Family Contact

Name of an emergency family contact.

Email for an emergency family contact.

Phone number for an emergency family contact.