Name:_______________________________________________ Today's Date:_____________
Social Security Number: _________________________________Date of Birth:_____________
Local Address:________________________________________________________________
Local Phone:_________________________ Permanent Phone __________________________
Permanant Address:____________________________________________________________
Permanant City:__________________________________ State:______ Zip: ______________
Do you work with Vocational Rehabilitation? Yes:________ No:________
If yes, what is your counselor's name? ______________________________________________
Where did you attend high school? ________________________________________________
Did you receive special education services in high school? Yes:________ No:________
Did you transfer from another college or university? Yes:________ No:________
If yes, where? _________________________________________________________________
Which of the following accomadations have you used in the past? Check all that apply.
_____books on tape _____note takers _____extra time on tests _____tests outside the classroom
_____word processor/hand held speller _____tutoring _____ interpreters other_______________
Do you need letters to take to your instructors regarding your disability? Yes:_______ No:_______
Please mark ALL that apply: I am requesting accommodations because I am an individual with...
________attention deficit disorder ________other physical impariment
________deafness ________physical impairment
________hard of hearing ________traumatic brain injury/closed head
________learning disability ________visual impairment
________mental illness ________other:_____________________________________________
If you are Deaf or 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 & board _____tutor _____note taker _____none
Are you receiving other forms of financial assistance? Yes:________ No:________
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______________________________________
Which assistive listening devices do you use?
_____FM system _____hearing aid _____loop _____none _____other
All students answer this question.
Please describe how your disability affects you in terms of school.