Bishop State Community College
Application Type: New Returning student Date:
Student Name: (Last) (First)
Student #: Age: Sex
Date of Birth:
Street Address:
City: State: ZIP:
Home Phone: ( ) Cell Phone: ( )
Emergency Contact Name/Phone
Campus: Semester Applying for Services
Major Expected Semester/Date of Graduation
Are you a client of the AL Department of Rehabilitative Services (ADRS) client? Yes No
Please provide the name of your Voc. Rehabilitative (VR) Counselor
Are you a veteran? Yes No
hat accommodations will you require? (Please specify)
Extra time to write tests Take tests orally
Record class lectures Utilize note takers
Reduced academic load to minimum full-time status
Special parking Handicap accessibility
Other _
OPTIONAL: This information is for state and federal reporting purposes only:
Ethnicity: African Asian Native American _ Hispanic Other
Other _
Student’s Signature: Date:
Services Rendered:
*** Please bring a copy of your class schedule each semester to the ADA office.
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