Q
UINCY
C
OLLEGE
|
PLYM OUTH & QUINCY C A M PUSES
FOCUSED ON TEACHING & LEARNING, ONE STUDENT AT A TIME
Quincy Campus, 1250 Hancock Street, Quincy, MA 023169 Suite 508
Plymouth Campus, 36 Cordage Park, Plymouth MA 02360 Suite 220
DISABILITY SERVICES OFFICE
DISABILITY SERVICE OFFICER: 617- 405-5915 FAX: 617-984-1792
http://www.quincycollege.edu/departments/disability-services
Created 08/05/13
STUDENT REGISTRATION FORM
Date ________________
Circle Campus: Quincy Plymouth
Name______________________________________________
Student ID Number ________________________ Date of Birth ________________
Address: ________________________________ City: ________________ State: _________ Zip: __________
Cell Phone Number________________________ Home Phone Number ________________
E-Mail address ______________________________ Age_______ Male_______
Female_______
Country of Birth: _____________________ Country of Citizenship: ______________________
Where do you work: Work Phone Number:
How did you find out about Disability Services Office?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
If you were referred, please check all that apply:
Professor/Faculty Member: □Parent(s)
□Physician
Faculty Advisor Academic Advisor __________________
Self-Referral □Student Success Coach:
Off-Campus Counselor or Therapist (e.g., Mass Rehab.):
Name _________________________ Agency:
Contact Information:
Other: (please specify):
Check Campus
Q
UINCY
C
OLLEGE
|
PLYM OUTH & QUINCY C A M PUSES
FOCUSED ON TEACHING & LEARNING, ONE STUDENT AT A TIME
Quincy Campus, 1250 Hancock Street, Quincy, MA 023169 Suite 508
Plymouth Campus, 36 Cordage Park, Plymouth MA 02360 Suite 220
DISABILITY SERVICES OFFICE
DISABILITY SERVICE OFFICER: 617- 405-5915 FAX: 617-984-1792
http://www.quincycollege.edu/departments/disability-services
Created 08/05/13
STUDENT REGISTRATION FORM PG2
1. Please describe your disability:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
2. In what ways does your disability impact your life and school experiences?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
3. What accommodations and services have you used in the past?
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
4. Describe the kind of assistance you are seeking from the Disability Services Office at this time:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
I certify by my signature or typed name that all of the above information is true and correct to the best
of my knowledge.
_____________________________ __________________________
Signature Date
Office Use Only:
Submit
click to sign
signature
click to edit
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