Fillable Name VIU student number VIU program or interest (Vancouver Island University)

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Name VIU student number VIU program or interest (Vancouver Island University)

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Country of origin: CANADA
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Last Updated: 2019 See over
Accessibility Services
Confidential Intake
Name VIU student number
VIU program or interest area Date of Birth
Email Phone #
International Canadian citizen Aboriginal Permanent Resident Protected person/refugee
enrolled in courses at VIU applied to VIU (not enrolled in courses) prospective (not applied)
Referred to Disability Services by: self instructor other: _____________________________________
Purpose of visit: ____________________________________________________________________________
Please check box below indicating disability:
Significant Hearing Loss Physical Chronic Health Mental Health Vision Autism ADD
Learning Disability Unknown
If multiple boxes checked, which disability category requires the most academic accommodation: ___________
____________________
Do you have disability documentation/diagnosis? Yes No
Learning barriers/areas of difficulty_____________________________________________________________
__________________________________________________________________________________________
Prior academic accommodations: Kurzweil note-taking recording extra exam time
assistive technology
other________________________________________________________________________________
Are you currently receiving Provincial student loans or grants? Yes No
BC Other Province: _______________
Will you be applying for a Student Loan? Yes No
Other funding? (Band, WCB, etc.)____________________________________________________________
If currently a student what VIU services are used? Counselling Aboriginal Services Health Centre
Learning Strategist Library Research Writing Centre
Date: ______________________________________
Last Updated: 2019 See over
Accessibility Services
Confidential Intake (continued)
CONSENT REGARDING COLLECTION & RELEASE OF INFORMATION
Your consent to exchange personal information is required as a condition of registration with Accessibility
Services. This information is collected, used, disclosed, secured & destroyed in accordance with the BC
Freedom of Information & Protection of Privacy Act.
Information will not be released without your signed consent, except under these circumstances:
imminent threat or danger to self or others,
a minor needs protection from abuse,
a court order.
I hereby give permission for VIU Accessibility Services to exchange information regarding my accommodations
and enrollment status with relevant VIU staff for the purpose of coordinating services.
I acknowledge that Director of Student Affairs/designate will have access to my file at Accessibility Services.
By signing below, I understand that my student number may be disclosed for the purpose of institutional
research related to effectiveness, retention and graduation rates of our students.
I acknowledge it is my responsibility to ensure all information pertaining to my disability is current & accurate.
I understand that to rescind or amend this consent I must notify the record holder in writing.
Signature: _____________________________________________ Date:____________________________
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Name VIU student number VIU program or interest (Vancouver Island University)

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Completed 20 May 2022

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