Longwood University Student Registration Form
Office of Disability Resources
About You
N
ame: ____________________________________________________ Date:__________________________________
First M.I. Last
LU Number: __________________________________________Date of Birth: _________________________________
C
ell Number: ____________________________________Permanent Number: _________________________________
L
ongwood E-Mail:______________________________________________@live.longwood.edu____________________
G
ender (Mark Only One): Racial/Ethnic Background (Mark Only One) :
______Male
______American Indian/Alaskan Native _____White/Caucasian
_____Female ______Asian/Native Hawaiian/Pacific Islander _____Multi-Racial
_____Other ______Black/African American _____Other
______Hispanic/Latino (including Puerto Rican)
D
o you receive Vocational Rehabilitation services (circle one)? _____YES _____ NO
If you answered yes, who is your case manager? ________________________________________________
Student Status, Please Check One
Prospective ______________________________________________________________________
Date of Anticipated Enrollment
N
on Degree Seeking ________________________________________________________________________
T
ransfer ________________________________________________________________________
Name of Previous Institution
U
ndergraduate ____________________________________ _________________________________
Date of First Enrollment Major/Degree
Graduate/Professional _____________________________________ ________________________________
Date of First Enrollment Degree
About Your Disability
1. Please state your diagnosed disability (ies) and the date of onset. ___________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
2. Please describe how your disability affects you both outside and inside the classroom, including testing a
nd
studying situations (use additional page if
needed).__________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
About Your Educational History
1. Did you have an IEP in school (check one)? ____YES ____NO
2. Did you have a 504 Plan in school (check one) ____YES ____NO
3. P
lease list any accommodations you have received in the past. _____________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
4. Did you receive assistance with physical access of buildings or classrooms? If so, please describe. __________
___________________________________________________________________________________________
___________________________________________________________________________________________
5. Did you receive any type of housing accommodation? If so, please describe. ___________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
6. Did you receive any type of assistive technology? If so, please describe. ______________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Adapted from the University of Wisconsin’s McBurney Disability Resource Center’s Student Intake Form
“To request the information provided in this document in an alternate format contact the Office of Disability Resources
at 434-395-2391(TRS 711)".
Revised June 2018
contact the Office of Disability Resources at 434-395-4935(TRS 711).
R
evised January 2011
3. Please write the name and phone number of your physician(s). _____________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Current Needs
Please list the accommodations you would like to have at Longwood:________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Does your disability affect any of the major life function listed below?
Please check the appropriate box for each of the following:
Activity Somewhat A Great Deal Activity Somewhat A Great Deal
Caring for Myself
Learning
Talking
Reading
Hearing
Writing/Spelling
Walking/Standing
Calculating
Lifting/Carrying
Memorizing
Sitting
Concentrating
Manual Tasks
Listening
Eating
Taking Exams
Working
Interacting w/ others
Sleeping
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