CNM DRC Accommodate
Student Information Form
First Name: ____________________________ Last Name: _________________________ MI: ________
Date of Birth: __________________________ CNM ID#:__________________________________________
CNM Email: ___________________________ Contact Email: ______________________________________
Phone (Cell) Number: ____________________ Second Phone Number: ______________________________
How did you find out about CNM Disability Resource Center? Check all that apply.
Adult Disability Service Provider ____
High School ____
CNM Dean ____
Medical Provider ____
CNM Instructor ____
Previous College / University ____
Family Member ____
Self-referred ____
Friend ____
Other ___________________________
Are you eligible for the Bridge Scholarship Yes / No ____ and/or Lottery Scholarship Yes / No ____?
In your own words describe your disability: _____________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
How does your disability affect you in class lectures, labs, studying, doing homework, and taking tests,
quizzes, exams? Select those that apply and explain.
Being prepared for class: If yes, ______________________________________________________________
Focus and concentration on mental activities: If yes, _____________________________________________
Focus and concentration on physical activities: If yes, ____________________________________________
Following Instructions: If yes, _______________________________________________________________
Hearing: If yes, ___________________________________________________________________________
Listening to lectures / presentations: If yes, ____________________________________________________
Math: If yes, _____________________________________________________________________________
Medical / physical condition: If yes, ___________________________________________________________
Medication side effects: If yes, _______________________________________________________________
Memorizing: If yes, ________________________________________________________________________
Note taking: If yes, ________________________________________________________________________
Organizing school documents, day planning, making and keeping appointments, etc: If yes, ______________
Psychological/emotional condition: If yes, ______________________________________________________
Reading: If yes, ___________________________________________________________________________
Remembering what you learned: If yes, ________________________________________________________
Remembering what you read: If yes, __________________________________________________________
Seeing / Visual Acuity: If yes, _________________________________________________________________
Speaking: If yes, ___________________________________________________________________________
Strength and endurance doing physical activities: If yes, ___________________________________________
Thinking, comprehending, concentrating: If yes, _________________________________________________
Understanding what you read: If yes, __________________________________________________________
Use of hands / fingers: If yes, ________________________________________________________________
Using proper written grammar, punctuation, spelling: If yes, _______________________________________
Walking / Mobility: If yes, ___________________________________________________________________
Working in groups such as class projects: If yes, _________________________________________________
Writing your thoughts: If yes, ________________________________________________________________
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How does your disability affect you in getting around on campus, in and out of classrooms, and movement
in the class room? Select those that apply and explain.
Difficulty / inability to walk: If yes, ____________________________________________________________
Difficulty sitting: If yes, _____________________________________________________________________
Limitations of using arms / hands: If yes, _______________________________________________________
Limitations of using your back: If yes, __________________________________________________________
Limitations of using fingers: If yes, ____________________________________________________________
Limitations of using legs / feet: If yes, _________________________________________________________
Medication side-effects: If yes, ______________________________________________________________
Physical stamina: If yes, ____________________________________________________________________
Do you have limitations participating in class activities outside of the classroom? Yes or No ____
If yes, why? _______________________________________________________________________
Do you need adaptive furniture? Yes / No ____If yes, why? _______________________________________
Do you need assistive animal services? Yes / No ____
Do you need assistive technology such as visual magnifier, audio recording, Braille, etc.? Yes / No ____
If yes, why? ________________________________________________________________________
Do you need books in alternative format? Yes / No ____If yes, why? _______________________________
Do you need captioning services? Yes / No ____
Do you need interpreter services, ex: American Sign Language? Yes/No ____
Do you need personal care attendant services? Yes / No ____
Do you use a wheelchair? Yes / No ____
Are you receiving services from any other adult service provider for individuals with disabilities? Check all
that apply.
Adult Disability Service Providers ____
Independent Living ____
Commission for the Blind ____
Social Security Beneficiary ____
Developmental Disability Waiver Disability ____
Veteran’s Administration ____
Division of Vocational Rehabilitation ____
Other Service Provider_______________________
Did you graduate high school? Yes / No____
Do you have a GED? Yes / No ____
If no, highest grade completed and year exited high school: Grade____ Year____
Were you in Special Education? Yes / No ____
If yes, what services did you receive? _____________________________________________________
Have you attended or graduated from a college or university? Yes / No ____
Are you currently transferring from or co-enrolled in another college or university? Yes / No ____
Have you received accommodations from a previous college or university? Yes / No ____
If yes, what accommodations did you receive? _____________________________________________
Have you ever been in any category of academic difficulty while attending CNM?
Yes / No ____ If yes, select all that apply:
Academic Probation ____
Course Repeat ____
Academic Suspension ____
Subject to Dismissal ____
Did your parent(s) or guardian(s) attend and graduate with a degree from a four-year college or university?
Yes / No ____
Are you a veteran? Yes / No ____
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Statement of Confidentiality and Services
Central New Mexico Disability Resource Center’s Mission is to advocate in partnership with students who have
disabilities by providing accommodations that promote an accessible educational environment.
The information you provide will be held in strict confidence.
The Disability Resource Center complies with the Privacy Act of 1974 and will not disclose any information
without your consent expect in the following situations: when we become aware of child abuse; when and
individual clearly presents danger to self or others; or when we are subpoenaed for records or testimony by
the courts.
CNM Disability Resource Center has permission to discuss my educational situation with CNM faculty and staff
who have a legitimate need to know.
The Rehabilitation Act, Section 504, of 1973 as amended and the Americans with Disability Act of 1990 as
amended govern colleges and universities. Having a Special Education IEP or a 504 Plan in high school does not
guarantee that a student will be eligible for disability accommodations at CNM.
Students receiving accommodations are responsible for meeting academic standards and degree
requirements.
Student Signature: ________________________________________________ Date: ____________________
Parent / Legal Guardian Signature: ___________________________________ Date: ____________________
Counselor Signature: ______________________________________________ Date: ____________________
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