Application for Accessibility Services
Name_______________________________________________________ Date: ________________
Date of Birth________________________ Are you a client of: Vocational Rehabilitation
Dept. of Veterans’ Affairs
Other__________________________
Name of Counselor ________________________________
Mailing Address_________________________________________________
_________________________________________________
Phone: Home______________ Cell_______________ email: __________________________________
Check all that apply:
____ Hearing Impairment ____Visual Impairment
____ Learning Disability ____Mobility Impairment
____ Head Injury ____Psychological/Emotional
____ Upper Body/Extremities ____Chronic Illness
Other (please specify) __________________________________________________________________
Name and address of High School or Health Care Professional:
___________________________________________________________________________________
Please describe how your disability affects your academic studies:
