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REQUEST FOR ACCOMMODATIONS FORM

REQUEST FOR ACCOMMODATIONS THROUGH DISABLED STUDENT SUPPORT SERVICES.

Please fill in all blanks. Place "n/a" in blanks that do not apply.

DOCUMENTATION SUBMISSION STATUS:
I have submitted documentation
I have not yet submitted documentation

PERSONAL INFORMATION
STUDENT NAME:
PREFERED NAME:
DATE OF BIRTH: KSU ID #: REFERED BY:
GENDER: VETERAN Yes     No
ADDRESS LINE 1:
ADDRESS LINE
2:
CITY: STATE: ZIPCODE:
PHONE:
KSU E-MAIL: (MUST BE KSU E-MAIL UNLESS CONTINUING EDUCATION)

ACADEMIC INFORMATION
CHECK ALL THAT APPLY:
Freshman Sophmore Junior Senior 4+ Years
Transient Student Transfer Student Graduate School Continuing Education
COLLEGE:
MAJOR:
FIRST SEMESTER AT KSU? Yes     No
PREVIOUS COLLEGE:


DISABILITY INFORMATION
CHECK ALL THAT APPLY:
Attention Deficit Hyperactivity Disorder (ADHD) Brain Injury Chronic Health Condition
Deaf/Hard of Hearing Learning Disability Mobility Impairment
Neurological Condition
Psychological Condition Visual Disability Autism Spectrum Other

IF OTHER, PLEASE LIST DISABILITY HERE:
DATE OF ONSET: DATE OF DIAGNOSIS:
CURRENT MEDICATIONS:
PLEASE DESCRIBE THE IMPACT OF YOUR DISABILITY IN AN ACADEMIC ENVIRONMENT:

ACCOMMODATIONS
W
HAT ACCOMMODATIONS HAVE YOU USED PREVIOUSLY (IF ANY)?
HIGH SCHOOL:
 

PREVIOUS COLLEGES:

LIST THE ACCOMMODATIONS YOU ARE REQUESTING (TESTING ACCOMMODATIONS, NOTETAKERS, ETC...):

Contact Nastassia Sanabria (nsanabria@kennesaw.edu) with any problems or concerns.

      

 
 

     
   

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