Disability Support Services For Students
SELF IDENTIFICATION FORM
 
Name: (First)______________ (M.I) ___ (Last) ___________________ Date ___/___/___
Permanent Address:
_____________________________________________________________
_____________________________________________________________
  City_____________________ State________ Zip___________
Phone (          )_____________________
Personal Data : Social Security Number ____/___/_____            ___ Male ___ Female

 

Ethnic Origin: (optional)
___ African American
___ Asian/Pacific Islander
___ Hispanic/Latino(a)

 ___ Native American
___ White
___ Other_________________________
Describe primary disability:
_______________________________________________________________________________
_______________________________________________________________________________
List other disabilities (if applicable):
_______________________________________________________________________________
AGENCY FUNDING: YES____NO____ RFCB/CFB: YES____ NO____
VESID (OVR) COUNSELOR:____________________________________________
OFFICE_____________________PHONE__________________________________
ANTICIPATED NEEDS AND ACCOMMODATIONS
Please indicate academic accommodations you would need: ________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Please indicate physical accommodations you would need:
________________________________________________________________________________
________________________________________________________________________________
What accommodations have you used in the past:
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Documentation of disability from a qualified professional is required in order to access services through the office of Disability Support Services for Students at SUNY College at Fredonia.
Return this form to:
Disability Support Services for Students
Learning Center, Reed Library (4th Floor)
SUNY Fredonia
Fredonia, NY 14063

For questions or information:
(716) 673-3270
TTY (716)673-4763
www.fredonia.edu/tlc