Accessibility Resources Clermont- Online Application for Services

Student's Full Name:

M#:

Have you used other names that might be on your submitted medical documentation?

Pronouns

UC Email:

Only UC email accounts can be used by Accessibility Resources to communicate with UC students.

Phone number:

Home College: Select the College of your primary major

Intended Major:

What semester are you requesting academic accommodations start in? (If you're an incoming Freshman starting in Fall 2020 please select Fall 2020)

Summer 2020

Fall 2020

Other...

Is this request due to an injury or illness that is temporary? (i.e., surgery, accident) If so, please explain?

Type Selection For what disability are you seeking accommodations?

Attention Deficit Hyperactivity Disorder ADHD

Autism Spectrum

Cognitive Disability

Chronic Illness

Deaf/Hard of Hearing

Learning Disability

Mental Health

Physical Disability

Visual Impairment/Bllindness

Other

Thinking about your disability and your experience with learning and engaging in the classroom, what are the main concerns you would like Accessibility Resources to assist you with?

If you have received accommodations or special education services in the past, which were the most helpful for you?

Are there any other areas of university life that might be impacted by the disability (housing, transportation, building accessibility, parking, etc.)?

During your registration meeting, will you require any accommodations? Please list any accommodations you would like to request.

Type Selection What is your preferred method for conducting your registration meeting?

In person

Video Conference (Teams, Zoom, WebEx, etc.)

Phone

Other

Please share any additional information you would like to provide.

Medical Professional Disability Verification Form or Supporting Disability Documentation

This field is required

Please upload your Medical Professional Disability Verfication form or documentation supporting your request for accommodation that meets Accessibility Resource's documentation guidelines. Note: JPEG, PNG, or other image files containing photographs of documentation will not be accepted and may delay review of your documentation. Please provide scanned PDF or digital documents.

Additional Documents: Upload any additional documentation, assessments, etc. in support of your request for academic accommodations

This field is required

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