X-Path Program Application

Student Information
Name Name First Last
Date of Birth
Email
Student Cell Phone
Home Phone
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code
Sex/Gender Identity
Family Information

Please enter two family contacts.
Contact 1 Contact 1 First Last
Contact 1 Phone
Contact 1 Email
Contact 2 Name Contact 2 Name First Last
Contact 2 Phone
Contact 2 Email
High School Information
School Name and Location
Counselor Name
Counselor Phone
Counselor Email
Did you have an IEP, 504 plan or other service plan while in K-12th Grade?

Did you have an IEP, 504 plan or other service plan while in K-12th Grade? Yes No
Intervention Specialist/Educational Support Professional Name
Intervention Specialist/Educational Support Professional Phone
Intervention Specialist/Educational Support Professional Email
Do you wish to apply for financial assistance?

Do you wish to apply for financial assistance? Yes No
Please list supports/programs that you utilized during high school (i.e. tutoring, individual or group therapy, occupational/speech therapy, etc.)
Academic Information
What is your intended major?
What supports help you learn best?
What are your concerns about transitioning to the college environment?
Are you planning to live on-campus?

Are you planning to live on-campus? Yes No
If yes, what are your concerns regarding living on-campus?
What are your personal interests?
What activities do you enjoy in your free time?
Diagnosis information
Please check off the diagnosis you have received that make you eligible for the X-Path Program

Please check off the diagnosis you have received that make you eligible for the X-Path Program Asperger's Disorder Pervasive Development Disorder, Not Otherwise Specified (PDD-NOS) Autism Spectrum Disorder ADD/ADHD Other, please specify
Please provide documentation of your diagnosis that include the following information:
- The name and contact information of the licensed professional who provided the diagnosis, along with the date the diagnosis was given.
- Please list and provide supporting documentation for any additional diagnoses that have been formally assessed.
- Current providers (psychologist, psychiatrist, counselor)
  
  If accepted into the X-Path Program you will be asked to sign an Authorization to Obtain and Release information so that we can communicate with your providers.
Additional Documentation

Attach Files
Personal Statement

Please provide a written statement that responses to the following questions:
1. Why would you like to be accepted into the X-Path Program?
2. What do you believe you will gain from participation?
3. How your participation will assist you in meeting your personal and academic goals?
Personal Statement

Attach Files
Terms
By submitting this form, I am agreeing to the following:

All information provided in this application is accurate and truthful.

Staff members in Xavier’s Office of Disability Services and the X-Path Program are permitted to speak with my family and treating providers for application purposes.

Terms
By submitting this form, I am agreeing to the following:

All information provided in this application is accurate and truthful.

Staff members in Xavier’s Office of Disability Services and the X-Path Program are permitted to speak with my family and treating providers for application purposes. Agree
Please type your full name as signature
Please add any additional information you wish to share

X-Path Program Application

X-Path Program Application

Student Information

Family Information

High School Information

Academic Information

Diagnosis information

Please provide documentation of your diagnosis that include the following information:

Personal Statement