ACCESSIBLE EDUCATION OFFICE
REGISTRATION FORM
Please submit the appropriate clinical documentation with this form. See guidelines for documentation on
our website at http://www.aeo.fas.harvard.edu/documentation.html
PERSONAL INFORMATION: (Please print clearly)
NAME:
__________________________________________
CELL PHONE:
____________________________________________
ADDRESS:________________________________
EMAIL: (current) ______________________________
__________________________________________
EMAIL: (alternate)
City
_______________________________________________
State
Zip
HARVARD ID# _________________________
I am: (circle one)
Incoming Freshman
Current College Student
GSAS Student
Transfer Student
Other
HEALTH CONDITION/DISABILITY INFORMATION: (Use separate sheet if more space is needed)
Name of health condition/disability
First diagnosed? ___________
Describe (1) your understanding of your disability and (2) its probable impact on your life at Harvard.
How and when have you used academic, testing and/or residential accommodations previously?
Do you use specialized equipment, including hardware/software? If yes, describe:
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ANTICIPATED NEEDS: (Please check anticipated needs, and add more as necessary)
 Extended examination time
Van Transportation
In-class note takers
Mobility Orientation
Accessible Classrooms

Emergency evacuation orientation related to your disability
Assistive Listening Technology
 _________________________________________________
Alternative format of Course Materials (specify)
Access to adaptive technology beyond your own (specify) __________________________________________
Sign Language, oral, cued speech interpreters (specify) ____________________________________________

Housing (specify) __________________________________________________________________________
_________________________________________________________________________________________
Other (specify)______________________________________________________________________
The information I have provided is accurate to the best of my knowledge.
I authorize AEO to consult, as needed, with clinicians to clarify documentation.
Student Signature
Date
Please submit the appropriate clinical documentation with this form: see guidelines for
documentation on our website at http://www.aeo.fas.harvard.edu/documentation.html. Even if you
have provided documentation to University Health Services or another Harvard office, you must send a
separate copy to this office. A personal interview to register with AEO upon arrival is required before
approved services can be implemented.
Mail or fax this form and your clinical documentation to: Accessible Education Office
Harvard University
1350 Massachusetts Avenue
Smith Campus Center, Fourth Floor
Cambridge, MA 02138
Phone: 617-496-8707
Fax: 617-496-1098
For Office Use Only:
Date received Registration Form: ___________________________
Date received Clinical Documentation: _______________________
Documentation Complete: Yes
No
If No, documents needed:__________________________________________________________
Sent for review: ______________________
Review Returned: ___________________