SMC Accessibility Resources Intake Form

SMC Accessibility Resources Intake Form

Accommodations Request Intake Form
Student Information
Full Student Name*

First NameLast Name
Student email*
example@example.com
Student Cell Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Student Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
SMC ID Number or Social Security Number*
First Semester at SMC*
Semester applying for service*
PLEASE BE SURE TO MARK YOUR DIAGNOSIS!
ADHD--Hyperactive Impulsive TypeADHD--Inattentive TypeADHD--Combined TypeADHD--Not Otherwise Specified
Autism Spectrum DisorderPervasive Developmental Disorder
DeafHard-of-Hearing
AllergiesAsthmaAutoimmune ConditionBack/ Neck ConditionDiabetes, Type IDiabetes, Type IIEpilepsyGastrointestinalMigraine HeadachesNarcolepsyNarcolepsy with CataplexyNeurological ConditionPOTSSeizure or Seizure-Like DisorderOther
Cerebral PalsyMuscular DystrophyMultiple SclerosisParaplegiaQuadriplegiaSpina BifidaOther
Adjustment DisorderBi-Polar DisorderDepressive DisorderEating DisorderGeneralized Anxiety DisorderObsessive-Compulsive DisorderPTSDSubstance AbuseOther
Auditory Processing DisorderDysgraphiaDyslexiaLanguage DisorderMath DisorderReading DisorderDisorder of Written Expression
Arm/ Hand/ Wrist InjuryBack/ Neck InjuryConcussionEar/ Eye/ Nose/ Throat InjuryLeg/ Foot/ Ankle InjuryPregnancyOther
Post-Concussive SyndromeTraumatic Brain InjuryOther
BlindLow-Vision
Please describe how your disability impacts your daily life.*
What is the date of the onset of your disability?*

MonthDayYear
What accommodations have you used in the past?*
AcademicDiningHousingOther
What accommodations are you requesting at SMC?*
You may upload your documentation here or email it to disabilityservices@smcsc.edu:

Cancelof
Date

MonthDayYear
Should be Empty:

SMC Accessibility Resources Intake Form

Student Information

PLEASE BE SURE TO MARK YOUR DIAGNOSIS!