Student Disability Form
We serve students with many different types of disabilities, and depending on your disability, certain accommodations may be needed to help you become successful on your academic journey. However, what is required is that you submit documentation that shows evidence of a disability. The information we receive from you is confidential and will only be used to assist you in having a successful educational experience. Every reasonable effort will be made to accommodate your needs in a timely manner. Please fill out the form as completely as possible so we may better serve you.

First Name *
Last Name *
Student ID#: *
Briefly explain what you need and/or what your medical or educational limitations are. *
What agencies are assisting you? *
What is your disability, medical condition, and/or learning difficulty? Please explain. *
Have you ever attended special education classes? *
If yes, please check all grades that apply: *
Have you ever attended personal or group counseling? *
If yes, is this support needed for your academic success? *
What services do you think would benefit your academic progress? (Please check all that apply) *
Additional Information (voluntary)
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