Intake Form
To be completed by student
Student Access Services, Room M2720
Phone: 303.797.5730 FAX: 303.797.5810
Name: Preferred Name:
Last First Middle Initial
Student ID: S Birthdate: Phone:
Student Email:
Gender (check all that apply): Male Female Non-Binary Transgender Other:
Preferred Pronoun: He She They Other:
Disability Information
You will need to provide a copy of your documentation (ex: IEP, 504, documentation from a licensed professional). If
you are a student who would like to self-disclose a disability, please respond to the following:
My disability is… Diagnosed Suspected, not diagnosed
Please describe the academic impact of your diagnosed or suspected disability, and list any related medications:
What accommodations have you used? (e.g., more time on tests, reading program, equipment, assistive technology):
ACC Status
Have you taken the Accuplacer? Yes No (Some students may be exempt based on SAT/ACT scores.)
Anticipated test date: (Registration is dependent on Accuplacer scores.)
Have you met with an Academic Advisor? Yes No Have you applied for Financial Aid? Yes No
Are you registered for classes? Yes No
First semester at ACC? Year: Fall Spring Summer
Are you currently enrolled in high school? Yes No
Student Intake Checklist
To be completed with Specialist
Discussion Points
Documentation Received (IEP, 504, Service Plan, Medical documentation)
Current accommodations are temporary. To continue accommodations, student will submit
documentation by the semester.
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Student Access Services Student Intake Checklist
To be completed with Specialist
Student Access Services, Room M2720
Phone: 303.797.5730 FAX: 303.797.5810
Accommodations were determined:
Discussed SAS sending accommodation letter to instructors and student’s responsibility to inform
SAS of schedule changes.
Discussed student’s responsibility to request accommodation letter each semester.
Discussed academic withdrawal dates (Refer to syllabus).
Discussed academic services (Student Success Center, Writing Center, Math Support Center, etc).
Discussed Testing Center’s use of video cameras to record and monitor testing.
Student Agreements (Check & initial all that apply or leave blank.)
Student signed Testing Procedures Form.
Student signed Recorded Lecture Agreement.
Student signed ASL/Captioning Service Agreement.
Scheduled an assistive technology training appointment with Assistive Technology Specialist.
Kurzweil Smartpen Other
Date & Time
I hereby authorize Student Access Services (SAS) to hold confidential information on this form, any records I provide,
as well as information shared by me or on my behalf with SAS staff. Information provided to SAS will not become part
of my academic record, but will remain in a limited-access file. Additionally, I authorize SAS to share information from
these records with other Arapahoe Community College staff members or volunteers on a need to know basis in order
to assist in the provision of services. I understand my records may be released to off-campus authorities as required
by law. I further understand these records are necessary in the determination of special services, statistical reporting
and funding purposes.
Student Signature Date
SAS Specialist Signature Date
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