Please check the level of limitation you experience as a result of your disability.
C : No Mild Moderate
No Mild Moderate
O Impact Impact Impact Impact Impact Impact Impact Impact
I am requesting (check all that apply):
Academic Accommodations(s) (e.g.: classroom, exams, e-text, etc.)
Campus accessibility (e.g.: doorways, elevators, lights, etc.)
Please list the accommodations you are requesting:
Please describe your previous educational experiences and the services you have received in the past (i.e., can be from
high school Special Education or 504 plan, accommodations on the ACT/SAT/GRE test, accommodations received at
other institutions of higher education, etc):
I agree that the disability coordinator may change my registration form from a “no” to a “yes” (if I have not al-
ready marked as such) to indicate that I am an individual with a disability.
I would like information about voter registration: Yes No