Voluntary Disability Disclosure
Western Carolina University is committed to providing equal educational opportunities for qualified
students with documented disabilities. Disability Services is responsible for assuring that facilities,
programs and services are accessible. Students who require disability services or accommodations must
identify themselves as having a disability and provide documentation from the appropriate professional
care provider about the disability, functional limitations, and recommendations for accommodations.
Documentation Guidelines are available on our website at www.wcu.edu/disabilities. All information is
confidential. Please call (828) 227-7234 for additional information.
Please complete and return this form and disability documentation to:
Kimberly Marcus, Director of Disability Services
460 HFR Administration Building
Western Carolina University
Cullowhee, NC 28723
I.
General Information
Name: __________________________________ Banner ID #: __________________________
Home Address:
____________________________________________________________
____________________________________________________________
____________________________________________________________
E-mail Address:
____________________________________________________________
Home Phone:
Classification:
__________________
Cell Phone: _____________________________
□ New Freshman □ Continuing Student
□ New Transfer
□Graduate Student
Semester Entering WCU: _____________________
Major: __________________________
Have you signed up with Student Support Services? ______________________________________
II.
Disability Information
What is the nature of your disability? (Check all that apply)
□
Learning Disability
□
AD/HD
□
Mobility Impairment
□
Chronic Illness
□
Hearing Impairment
□
Deafness
□
Speech Impairment
□
Visual Impairment
□
Blindness
□
Psychological Disorder
□
Other (please specify): _________________________________
Are you a client of a state/federal rehabilitation agency? Please check all that apply:
□ Division of Vocational Rehabilitation
□ Division of Services for the Blind
□ Veteran’s Administration
The information on this form is true and accurate to the best of my knowledge. By signing this form I authorize
Disability Services staff to receive medical and/or psychological information regarding my disability and to
contact my health care professional or other informed individual to obtain further information if necessary.
________________________________________
Student Signature
_______________________________
Date
**Please attach documentation of your disability to this form.