Course Name
*
Name
*
First Name
Last Name
Phone
*
(###)
###
####
Email
*
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Primary Disability
*
ADD/ADHD - attention deficit disorder, attention deficit/hyperactivity disorder
CMC - chronic medical condition
ED - eating disorder
HD - hearing disability, hearing loss
LD - learning disability
MD - mobility disability
Other
PD - psychological/psychiatric disability
SA - substance abuse/recovery
TBI - traumatic brain injury
Temporary condition - please specify below
VI - visual disability/blindness/low vision
Secondary Disability(ies)
Other Disability or Note:
Who were you referred by?
*
Do you want to identify a parent/guardian that we may contact in case of emergency? If so, please indicate name and phone number.
*
Contact information
When were you first diagnosed with your disability/ condition(s)?
*
Current treating clinician & contact information:
*
Are you currently taking any medications related to your disability/condition(s)? If so, please list below.
*
Have you ever had an IEP or Section 504 plan or received accommodations in high school? * (Selection is Required)
*
Please list any previous accommodations you have received:
*
Do you have a temporary injury that impacts you academically (i.e. concussion, broken wrist)? If so, please specify below along with the approximate date of the injury.
*
Please describe how your condition/disability impacts you academically (i.e. reading, writing, concentration, memory, time management):
*
Do you currently use any assistive technology (i.e. Dragon Naturally Speaking, JAWS, Read out Loud, etc.)? If so, please specify:
*
