Services for Students with Disabilities
Science Building Room 132
Phone 718 631 6257
FAX 718 281 5733
Application for Services & Accommodations
Name:
Date:
/
/
ID #:
D.O.B:
/
/
Address:
Phone #:
Cell #:
E-mail:
Name of High School or College previously attended:
Nature of Disability (check all items that apply to you):
 Learning Disability
 Physical Disability (Mobility Impairment)
 Deaf
 Hard of Hearing
 Epilepsy/Seizure Disorder
 Visual Impairment or Blind
 Substance Abuse
 Psychological
 Chronic Medical Condition (Please Indicate):
 Other (Please Indicate):
Are you taking medication due to your disability?
 Yes (Please list medications):
 No
Students diagnosed with a
disability that request services
or accommodations are required
to provide appropriate and
current documentation in order
to be considered for
accommodations.
Are you submitting
documentation at this time?
 Yes
 No
Please indicate the accommodations that you are requesting:
Note: Each accommodation requested must be supported by appropriate documentation. You
will be advised of approved recommendations based upon your submitted application.
Sponsoring Agencies:
 ACCES-VR– Name of Counselor:
 Commission for the Blind and Visually Handicapped (CBVH)
 Veteran’s Administration
 Other (Please Indicate):
This office is a National Voter Registration Site and can assist you with the
process of registering to vote. Would you like to register to vote?
 Yes
 No
 No, already registered to vote
The office of Services for Students with Disabilities is also available to assist you with
registration, advisement, advocacy efforts, and as a general resource for you on
campus. Please always feel free to schedule an appointment for assistance.
I understand that this application is a request for services. Determination of
eligibility for requested accommodations will be based upon review of supporting
documentation.
X
Student Signature
Date