Center for Student Accessibility (CSA) Services Interest Form
Thank you for your interest in the Center for Student Accessibility (CSA). Please fill out the information below and a CSA Representative will contact you within 24-72 hours.
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address:
*
student@my.pbsc.edu
Date of Birth:
*
-
Month
-
Day
Year
Date Picker Icon
Please select which represents you: (Select one)
*
Current PBSC Student
New Student (Applied to PBSC)
New Student (Have not applied to PBSC)
PBSC Student ID Number:
What is your intended program of study: (Select one)
*
AA/AS Degree Seeking
Bachelors
Certificate
Dual Enrollment/Early Admit
Undecided
Please list current high school:
Which campus are you planning to attend? (please select all that apply):
Belle Glade
Boca Raton
Lake Worth
Loxahatchee Groves
Palm Beach Gardens
PBSC Fully Online
Preferred method of contact:
Email
Phone
Availability for a Follow-up Meeting:
*
8:00am to 1:00pm
1:00pm to 5:00pm
5:00pm to 7:00pm
Submit
Should be Empty: