DSS/STEEP Information Sheet
Welcome to Disability Support Services at Molloy College. If you are interested in registering with us, please fill out the form below. If needed, any information may be changed at a later date.
Email address *
First name *
Your answer
Last name *
Your answer
Date of birth (make sure to change the YEAR) *
MM
/
DD
/
YYYY
Address (include city and state) *
Your answer
Alternate email address
Your answer
Cell phone (include area code) *
Your answer
Alternate phone (home)
Your answer
Molloy Student ID #:
Your answer
I am currently (check all that apply) *
Required
I am participating in *
Required
Please list the name(s) of your high school(s).
Your answer
If you attended any other college or university, please list below.
Your answer
Is this your first time EVER requesting reasonable accommodations based on disability or chronic illness?
Please state the disability or chronic illness for which you may be requesting accommodations.
Your answer
Please give a brief description.
Your answer
When was your disability or chronic illness first diagnosed (approximately)?
If it affects your academic performance, please describe how.
Your answer
How else does it impact you (socially, personally)?
Your answer
Have you declared a major?
If so, what is it?
Your answer
If undecided, what career(s) do you think you might enjoy?
Your answer
Are you planning on participating in sports at Molloy College?
If so, please specify which:
Your answer
Do you plan to or are you currently living on campus?
Would you be interested in participating in a discussion group? DSS/STEEP Discussion Groups are a place for students to bring lunch and chat. Dessert is provided.
L.E.A.D. is a Molloy College club (Leadership, Education, and Awareness of Disabilities). It is open to ALL Molloy students who have an interest in spreading awareness. Would you like to be added to the mailing list now?
Please feel free to tell us something about yourself that you would like for us to know.
Your answer
A copy of your responses will be emailed to the address you provided.
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