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DOCUMENTED DISABILITY: Check all that apply: 

  • Acquired Brain Injury
  • Developmental Disability
  • Orthopedic Impairment
  • ADD/ADHD
  • Health Impairment
  • Psychiatric Disability
  • Blind/Visual Impairment
  • Language Impairment
  • Speech Impairment
  • Deaf/Hard of Hearing
  • Learning Disability
  • Other

Is the above condition: 

  • Permanent/Chronic
  • Temporary

Instructional: 

  • Braille
  • Disability Related Absence
  • Large Print
  • Spelling Accommodation
  • To Record Lectures
  • Textbooks in Alternate Format

Testing: 

  • Alternate Format
  • Calculator
  • Computer/Word Processor
  • Distraction Reduced Site
  • Extended Time
  • No Scantron
  • Reader
  • Writer/Scribe
  • Spell Checker

Support: 

  • Interpreter
  • Lab Assisstant
  • Note taking assistance
  • Personal Care Assistant
  • Support Animal
  • Writer/Scribe
  • Wheelchair

Environment: 

  • Accessible Site
  • Adjustable Table
  • Preferential Seating
  • Space for Wheelchair
  • Special Seat
  • Paratransit

Equipment: 

  • CCTV
  • Closed Captioning
  • Listening Devices
  • Low Vision Aids

By checking this box I agree that the signatures of the above student and/or guardian are who they stated