Application for Services
Name
Today's Date (mm / dd / yy)
EKU ID Number
Date of Birth (mm / dd / yy)
Local Address
Local Phone
Permanent Phone
Permanent Address
Permanent City
Permanent State
Permanent Zip Code
Year in College Major
2 year degree 4 year degree
Do you work with Vocational Rehabilitation? (Check if yes)
If yes, what is your counselor's name?
Where did you attend high school?
Did you receive academic accommodations in high school? (Check if yes)
Did you transfer from another college or university? (Check if yes)
If yes, where?
Which of the following accommodations have you used in the past? Check all that apply.
Books on tape Extra time on test Note takers Tests outside the classroom Word processor/hand held speller Tutoring Interpreters Other
Do you need letters to take to your instructors regarding your disability? (Check if yes)
Please mark all that apply: I am requesting accommodations because I am an individual with.......
Attention Deficit Disorder Deafness Hard of Hearing Mental Illness Visual Impairment Traumatic Brain Injury/Closed Head Injury Physical Impairment Learning Disability Other
I use the following assistive technology:
Calculator Assistive listening device Electronic spell check Tape recorder Tape player/books on tape Portable note taker Jaws software Dictation system Laptop Zoomtext Read and Write Gold Other specialized computer software - describe
What assistive technology would you like to use?
If you are hard of hearing, please answer the following questions. If not, skip to the next section.
Check all services that Vocational Rehabilitation provides:
Tuition Books Room and Board Tutor Note taker Interpreter None
Are you receiving other forms of financial assistance? (Check if yes)
Check the situation that most closely describes your high school.
Mainstreamed regular classroom Special education class-all day Residential school-attend during day only Residential school-live on campus
Which communication system do you use?
ASL PSE Other (Please describe below)
Which assistive listening devices do you use?
FM System Hearing Aid Loop T-coil (phone switch) Other None
Please describe how your disability affects you as a college student on campus and in class.
Press this button to submit the application
Press this button to clear the application and start over