DISABILITY SUPPORT SERVICES (DSS)
Big Bend Community College is committed to ensuring its services, programs and facilities are
accessible to individuals with disabilities. DSS provides accommodations and support services
for students with documented disabilities. If you are interested in requesting services, please
complete this form and return it to the DSS office, room 1472. Questions? Call 509.793.2027
TDD: 509.793.2325
Name: __________________________________
Birth Date: __________________________
Student ID#: _______________________
Email: ___________________________________
Address: ____________________________________________________________________
Home Phone: ________________ Cell Phone: ________________ Today’s Date: ________
BBCC Start Date: ☐SUMMER ☐FALL ☐WINTER ☐SPRING YEAR: ________
Check all disability categories that apply:
☐1) Deaf/Hearing
☐(A) Deaf
☐(B) Severe to moderate hearing loss
☐2) Mobility
☐(C) Limited gait or range of motion
☐(D) Paraplegic
☐(E) Quadriplegic
☐3) Speech/Language
☐(F) Speech or language disorder
☐4) Learning Disability
☐(G) Attention deficit disorder
☐(H) Dyslexia or processing deficits
☐5) Blind/Visual
☐(I) Blind
☐(J) Visual disorders other than blind
☐6) Chronic/Acute Health
☐(K) Cancer
☐(L) Cardiovascular/pulmonary
☐(M) Orthopedic conditions
☐(N) Organ, blood, gastrointestinal,
connective tissue, immune disorders
☐7) Neurological/Nervous System
☐(O) Motor neuron
☐(P) Acquired brain injury
☐(Q) Developmental disability
☐8) Psychological/Emotional
☐(R) Mental disorders
☐(S) Autism spectrum disorders
☐Other (specify) ______________________
Internal use only DSS Code: revised: 4.8.19
