Accessibility Services Student Intake Form

If you are receiving assistance from any outside agency (i.e. Department for the Blind & Vision Impaired, Department of Rehabilitative Services, SSI benefits, etc.) for academic, career, personal counseling or support please provide contact information for that agency here.

Check the services/academic adjustments that you have used before and/or those you feel will be helpful to you. Select all that apply.

Documentation of your disability is required in order to determine your eligibility for academic accommodations. Please have your medical professional send Accessibility Services documentation of your disability clearly outlining the functional limitation that would keep you from having an equal opportunity while pursuing your educational program.

The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a federal law that protects the privacy of student education records. In accordance with FERPA, the university may not disclose certain education records or information contained there without written permission from the student. By signing below, I am indicating that Accessibility Services has my permission to discuss my disability accommodations with my medical professional and with university departments for the purpose of arranging my academic accommodations.

Please review your rights and responsibilities at this link.