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Accessibility Services Center (ASC) Accessibility Intake Form
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Student Information
Please enter your information
First Name
Required
*
Last Name
Required
*
Middle Name
Student ID
Required
*
Preferred Name
Preferred Pronouns
She/Her
Him/His
They/Them
Other
Other Preferred Pronoun
Preferred Language
Email
Required
*
Please use your college issued email address
Alternate Email Address
Phone Number
Required
*
Starting Semester & Year
Example: Fall, 2020
Housing Status
Resident
Commuter
Referred to ASC by whom?
[select]
Academic Advisor
Faculty Member
Myself
Parent/Guardian
Peer
Other (Please Specify)
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Other Referral Source
Are you transferring from another college or university?
Are you transferring from another college or university?
Yes
Are you transferring from another college or university?
no
If yes, which college/university did you attend?
If not yet enrolled, planned date of enrollment
January
February
March
April
May
June
July
August
September
October
November
December
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31
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
Are you a graduate student?
Required
*
Are you a graduate student?
Yes
Are you a graduate student?
no
What graduate program are you in?
Required
*
Are you a doctoral student?
Required
*
Are you a doctoral student?
Yes
Are you a doctoral student?
no
What doctoral program are you in?
Required
*
Guardian First & Last Name
Guardian Phone Number
Guardian First & Last Name
Guardian Phone Number
Specific Disability/Accommodation Information
What is your disability or disabilities?
Required
*
[select]
Attention Deficit Hyperactivity Disorder (ADHD)
Autism Spectrum Disorder Related
Chronic Medical Condition
Cognitive Impairment
Communication Impairment
Hearing Impairment
Learning Disabilities
Mobility Impairment
Psychological Condition
Temporary
Visual Impairment
Other
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Other Disability or Disabilities
Have you ever received accommodations in high school or another institution?
Have you ever received accommodations in high school or another institution?
Yes
Have you ever received accommodations in high school or another institution?
no
If so, which accommodations were provided?
Have you ever received accommodations through the ASC?
Have you ever received accommodations through the ASC?
Yes
Have you ever received accommodations through the ASC?
no
If yes, please provide dates
What category of accommodations are you requesting?
Required
*
Academic Services
Housing
Meal Plan
Transportation
Other (Specify Below)
Parking
If other, please specify
Specific accommodations being requested.
Required
*
Please provide a description of how your disability affects your daily life and any additional information for this request.
Upload supporting document(s)
Agreement
Required
*
By checking this box, I certify that the above information is correct.
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