Name: _________________________________ Birth Date: _____________________________
Student ID#: _______________________ Email: ______________________________________
Address: _______________________________________________________________________
Home Phone: ________________ Cell Phone: ________________ Today’s Date: ____________
Please answer the following questions:
Please list all schools you have attended in the past:
What is the highest grade you completed?
Did you attend special education classes? If yes, in what subjects?
Have you ever had a serious illness? What was the nature of the illness?
Have you ever had a serious accident? Describe it.
Have you ever had problems with alcohol or drugs? If yes, did you receive treatment?
Have you ever received treatment or counseling for personal or emotional problems?
Are you presently under a doctor’s care? If yes, for what condition(s)?
What medications are you taking, if any?
What kinds of jobs have you held in the past?
Describe your abilities in the following areas:
Listening Skills
Have you been diagnosed with a learning disability? If yes, please describe:
What career field or occupation do you hope to enter?
What are your favorite hobbies?
Please list any doctors, caseworkers, counselors, etc. that know of your disability:
Describe your disability in your own words:
How does your disability affect you as a student in a learning environment?
What ideas or strategies have you found that help you as a student?
Knowing your own disability, your energy level, and time commitments, what would be a realistic class
load for you?
Additional information you feel Disability Support Services should know:
Return this packet to:
Big Bend Community College
Disability Support Services
Building 1400, Room 1472
7662 Chanute St. NE
Moses Lake, WA 98837-3299
Phone: 509.793.2027 or 509.793.2035
Toll Free: 1.877.745.1212
TDD: 509.793.2325