Hagerstown Community College
Disability Support Services (DSS)
CONFIDENTIAL
Student Intake
CONTACT INFORMATION:
First Name: _________________________________ Last Name: ____________________________________
Address: __________________________________________________________________________________
City: _______________________________________ State: _________ Zip Code: ______________________
Telephone: (Home) _______ - ________ - __________
(Other) ________ - ________ - _________
Student ID#:___________________________ Preferred E-mail: _______________________________
Classification
(select one): New Student Transfer Student Returning Student (date of last attendance):_______
Intended Major: __________________________________
MEDICAL BACKGROUND:
Date of diagnosis/documentation:__________________________________
What is your diagnosed disability/disabilities?_____________________________________________________
Describe your disability and how if affects your performance as a student. ______________________________
__________________________________________________________________________________________
List any services that you have received from outside agencies (ex. DORS) for academic, career, or personal
counseling, etc. _____________________________________________________________________________
ADDITIONAL INFORMATION:
Do you receive SSDI(Social Security Disability Insurance)
select one: YES NO
You may be eligible to receive a tuition waiver if you are an SSDI recipient.
I have received a (select one): High School Diploma Certificate of Attendance Neither
Are you currently working? _______________ How many hours per week? ____________________________
What is your educational goal? ________________________________________________________________
