SARC Application for Services - East Georgia State College

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SARC Application for Services - East Georgia State College - Statesboro campus

This form is to be completed only if you have a disability and are requesting academic accommodations. The information on this form is confidential and will only be released to those individuals responsible for providing assistance to students with disabilities.

Email *

Please check the area(s) that best describe(s) your disability: *

Acquired Brain Injury

AD/HD or ADD

Autism Spectrum Disorder

Communication Disorder

Deaf or Hearing Impairment

Learning Disability

Mobility Condition

Physical / Medical Disability

Psychological Disability

Visual Impairment or Blind

Other:

Required

First Name: *

Last Name: *

Middle Name:

Preferred Name:

Student ID Number: *

Date of Birth: *

YYYY

Gender: *

Female

Male

Transgender

Non-binary

Not specified

Prefer not to answer

Cell phone number (enter 10 digit number):

Landline phone number (enter 10 digit number):

Local Address:

EGSC Email address: *

Student Status:

First time beginning freshman

Returning student

Transfer

Clear selection

Semester and Year that I plan to begin attending Georgia Southern:

The documentation that you provide to the SARC may be shared with the Regents Center for Learning Disorders for review in consideration of academic accommodations requested. Please type your name if you consent to the release of your information. By typing your name, you are confirming that you are the student completing this form. Student signature:

A copy of your responses will be emailed to the address you provided.

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