Student Intake Form

Student Information

Please enter your information

First Name

Legal First Name

Last Name

Middle Name

Campus Key

Email

Please use your university issued email address

Home/Cell Number

Did you attend an institution previously?

Campus Affiliation

Campus

College/School

Degree Level

Program

Specific Accommodation Information

What is your diagnosed disability?

If other please describe:

Date of Diagnosis

Describe how the learning environment impacts your disability and academic experience

What are your limitations with respect to the learning environment in higher education?

What specific accommodations are you requesting?

Additional information:

Please share any additional information you wish to share with our office here:

Release of Information

I give the staff from Student Accessibility Services permission to disclose and discuss information regarding my need for accommodations, including medical or personal health information to faculty and staff directly involved in reviewing, determining and providing accommodations at the University.

I understand this information will be maintained in a confidential manner and this release will remain active unless I withdraw it. I understand I have the right to withdraw this release at any time by providing written notice of withdrawal to The Office of Student Accessibility Services. I understand that any future withdrawal will be effective as to future disclosures only and that the University cannot recover information once is has been released.

Additional persons authorized to receive information include:

Example: Parents, Guardians

Signature

Date

Documentation

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