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home > current students > student life > disability services > procedures for requesting accommodations

Application for Services

Students with disabilities may complete this form so that appropriate services can be considered. Please be aware that additional information may be required before students are eligible for disability services. All information provided is kept confidential.

Social Security or Student Number  

First Term Requesting Services Semester   Year 20  

Last Name  
First Name   MI   Suffix  

Local Address:

Address  
Apt/Suite/Rm/etc  

City   State   ZIP Code  

Permanent Address:

Address  
Apt/Suite/Rm/etc  

City   State   ZIP Code  

Phone Number  
Cell Phone Number  

Email  
Confirm Email  

Type of Disability: Documentation must be provided for each disability you select (hold the Ctrl key to make more than one selection)

Other (explain)  

I understand that this application is for disability services and has no bearing on admission to a particular program or college. ODS will accept the electronic submission of this application as your signature.


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