Fillable Shoreline Community College - Disability Services Student Information Form

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Shoreline Community College - Disability Services Student Information Form

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The Shoreline Community College - Disability Services Student Information Form form is 1 page long and contains:

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Country of origin: US
File type: PDF

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BROWSE SHORELINE COMMUNITY COLLEGE FORMS

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16101 Greenwood Ave North • Shoreline, WA 98133-5696 • (206) 546-4545 • www.shoreline.edu
Shoreline Community College does not discriminate on the basis of race, color, national origin, sex, disability, or age in its program and activities. The
following person or persons has/have been designated to handle inquiries regarding the non-discrimination policies:
Dr, Tonya Drake/Vice President Student Success, Rm: 5202, 206-546-6910, tdrake@shoreline.edu
Student Information Form
Last Name ___________________________ First Name _________________________
Street Address ___________________________________________________________
City State Zip Code _____________
Daytime Phone ______________________ Evening Phone ___________________
Permission to leave detailed message Permission to leave detailed message
E-mail Address __________________________________________________________
Emergency Contact _______________________ Emergency Phone _______________
Student Identification Number _________________________________ M F
Please check all that apply:
Deaf
Hard of hearing
Mobility
_____ Limited gait
_____ Limited range of motion
_____ Paraplegic
_____ Quadriplegic
_____ Other spinal cord injury
_____ Other __________________________________________________
Speech or Language Disorder
Diagnosed Learning Disability
ADD/ADHD
Blind
Visual Disorder
Chronic/Acute Health
_____ Cancer
_____ Cardiovascular
_____ Pulmonary
_____ Other __________________________________________________
Acquired Brain Injury
Developmental Disability
Orthopedic condition
Medical Condition
____ Renal disease
____ Diabetes
____ Lupus
____ CFS
____ HIV/AIDS
____ Fibromyalgia
____ Allergy
____ Other ______________________
Neurological/Nervous System
____ Cerebral Palsy
____ Seizures
____ Multiple Sclerosis
____ Tourette Syndrome
____ Parkinson’s
____ Peripheral Neuropathies
____ Muscular Dystrophy
____ Other ______________________
Psychological/Emotional
Diagnosis___________________
Other__________________________
(please specify)
Home
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Home
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SERVICES FOR STUDENTS
WITH DISABILITIES
■
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Shoreline Community College - Disability Services Student Information Form

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Completed 27 May 2020

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