Special Populations Self Disclosure Form

The Special Populations office is designed to assist students with support services, resources referrals, customized workshops and life skills. The program provides effective guidance to assist students in overcoming barriers to stay in school and achieve their career goals. Please fill out this form so it would better help us serve you.

Please indicate below which of the following best describes your current status:

Are you a person who has the primary or joint custody for a dependent child? You may be divorced, widowed, legally separated, or never married.
Are you a person who has cared for a home and family without pay; who has been financially supported by another family member in the past; who is unemployed or underemployed and having difficulty in obtaining and upgrading employment or who has custody of a child with less than two years remaining to receive assistance from Title IV of the Social Security Act?
Eligible for Pell Grant or receiving federal assistance such as Foodstamps and/or
Student enrolled in program where 25% or less of gender employed within the

If you answered yes to be contacted by phone please fill in your phone number.

Albany Technical College does not discriminate on the basis of race, color, creed, national or ethic origin, gender, religion, disability, age, veteran status, or citizenship status (except in those special circumstances permitted or mandated by law). The section 504/ADA Coordinator is Ms. Regina Watts, 430-2854. The Title IX and Title II Coordinator is Ms. Kathy Skates, 430- 3524. The Title VI Coordinator is Mr. Joe Dan Banker, 430-3511.