1) Name
Social Security #
2) Current Address
3) Phone
TDD Phone
Fax
4)
Applying for Admission Accepted for Next Semester
Freshman
Sophomore
Junior
Senior
Other
Major
5) Please list the names, addresses and phone numbers of each of your
current physicians, therapists, counselors or other support services
providers below. Indicate the person's role (e.g. Mary Smith, speech
therapist, 123 East 4th St, Rapid City 555-6789)
6)Do you receive assistance from Vocational Rehabilitation or Services
for Visually Impaired?
Yes
No
7) Disability type: (please check all that apply)
Hearing
Learning Disability
Neurological Condition
Psychological/Psychiatric Condition
Speech
Mobility
Attention Deficit Disorder
Respiratory Condition
Other (please describe)
8) Are you currently taking medication for your disability?
Yes No
9)Did you receive support or special services for disabilities while
in high school?
No
If yes, please describe.
10) Please check all of the adaptive equipment you use on a regular basis
Cane
Lap Board
Head Pointer
Laptop Computer
Magnification Equipment
Speech Transmission Device
Manual Wheelchair
Crutches
Communication Board
Hand Splints
Lift-equipped Van
Assistive Speech Device
Tape Recorder
Talking Equipment
Power Wheelchair
Transfer Equipment
Other
11) Where will/do you reside during the school semester?
On-Campus
With Parents
Own Home or Apartment
Shared Home or Apartment with Friends
12) Will you require assistance for personal needs on campus?
Yes No
13) Have you been or are you frequently absent from school as a result
of medical problems?
Yes No
14) Check all of the services you think you may need. Please note: Not
all of these adaptations may be available at this time.
Extended Test-Time
Interpreter
Reader
Accessible Classrooms
Enlarging Equipment
Lab Assistant
Alternate Testing Sites
Computer Adaptations
Preferred Registration
Note-Taker
Wheelchair Storage
Scribe
Accessible Residence Hall Accommodations
Taped Text Books
Taped Lectures
Taped Exams
Other
Enter the sum of the two numbers: 46 + 44 = 