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Accessibility Services Student Intake Form

University of Maryland Global Campus Asia
Students
Student Life and Support
Accessibility Accommodations
Forms to Request Accessibility Accommodations
Accessibility Services Student Intake Form

Complete the accessibility intake form to initiate your accommodations request.

I. General Information

Full Name* * Required

This field is required.

Student ID #* * Required

This field is required.

E-mail Address* * Required

This field is required.

example@example.com

Address* * Required

This field is required.

City* * Required

This field is required.

State* * Required

This field is required.

Zip Code* * Required

This field is required.

Home Phone

Cell Phone

Work Phone

Undergraduate* Part-time Full-time Visiting Student Master Doctorate

This field is required.

Term* Fall Winter Spring Summer

This field is required.

Military Active Duty Veteran Reserve/Guard

Location* US Asia Europe

This field is required.

Major* * Required

This field is required.

II. Disability Information

What is your diagnosed disability? (Check all that apply)* Deaf/hearing impaired Mobility impaired Speech impairment Blind/visually impaired Learning disability Mental health impairment ADD/ADHD Other Health impairment

This field is required.

Please describe your disability and how it affects your performance as a student* * Required

Thsi field is required.

Please indicate the support service/accommodations you are requesting and how they will help you* * Required

Thsi field is required.

What kinds of special equipment or auxiliary aids do you use on a regular basis?* * Required

Thsi field is required.

Agency Information

Are you receiving assistance from any outside agency (i.e. Department for the Blind & Vision Impaired, Department of Rehabilitative Services, SSI benefits, etc.) for academic, career, personal counseling or support?

Select* Yes No

This field is required.

1. Agency Name

Phone #

Fax #

City or County

Counselor's Name

2. Agency Name

Phone #

Fax #

City or County

Counselor's Name

III. Support Services/Academic Adjustments

Check the services/academic adjustments that you have used before and/or those you feel will be helpful to you at UMGC. You may check more than one.

Tutoring* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Note Taker* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Reader* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Scribe* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Recorded lectures* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Extended test time* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Testing in a separate room* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Audio textbooks/materials* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Spell checker* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Voice synthesizer* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Word processor* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Voice recognition software* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Adapted keyboard* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Franklin speller* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

CCTV* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Talking calculator* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Braille* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Interpreter services* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Phonic ear* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

Enlarged print materials* Have Used Have Not Used Very Helpful Not Helpful

This field is required.

IV. Educational Background

Check the tasks that you can do easily and those with which you have difficulty.

Paying attention in class* Easy Task Difficult Task

This field is required.

Completing assignments* Easy Task Difficult Task

This field is required.

Taking notes* Easy Task Difficult Task

This field is required.

Memorizing* Easy Task Difficult Task

This field is required.

Managing time* Easy Task Difficult Task

This field is required.

Reading at a good rate of speed* Easy Task Difficult Task

This field is required.

Understanding what I read* Easy Task Difficult Task

This field is required.

Doing math calculations* Easy Task Difficult Task

This field is required.

Following directions* Easy Task Difficult Task

This field is required.

Spelling* Easy Task Difficult Task

This field is required.

Finishing tests on time* Easy Task Difficult Task

This field is required.

Putting thoughts into writing* Easy Task Difficult Task

This field is required.

Proofreading* Easy Task Difficult Task

This field is required.

Being motivated* Easy Task Difficult Task

This field is required.

Asking for help* Easy Task Difficult Task

This field is required.

Documentation of your disability is required in order to determine your eligibility for academic accommodations. Please have your medical professional send Accessibility Services documentation of your disability clearly outlining the functional limitation that would keep you from having an equal opportunity while pursuing your educational program.

The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a federal law that protects the privacy of student education records. In accordance with FERPA, UMGC may not disclose certain education records or information contained there without written permission from the student. By signing below, I am indicating that Accessibility Services has my permission to discuss my disability accommodations with my medical professional and with UMGC departments for the purpose of arranging my academic accommodations.

Signature or e-signature required* * Required

This field is required.

Date Signed

Contact Us

Our helpful admissions advisors can help you choose an academic program to fit your career goals, estimate your transfer credits, and develop a plan for your education costs that fits your budget. If you're a current UMGC student, please visit the Help Center.

Personal Information

First Name * * Required

This field is required.

Last Name * * Required

This field is required.

Contact Information

Email Address * * Required

Please recheck your email address.

This field is required.

Phone * * Required

Numbers only, between 10-15 digits.

This field is required.

International numbers, start with a plus sign (+) & country code

Location * * Required

This is a required field.

Additional Information

Degree of Interest * * Required

This field is required.

Academic Area of Interest * * Required

This field is required.

U.S. Military Affiliation (if applicable)

By submitting this form, you are giving your express written consent without obligation for UMGC to contact you regarding our educational programs and services using e-mail, phone, or text, including automated technology for calls and/or texts to the mobile number(s) provided. For more details, including how to opt out, read our privacy policy or contact an admissions advisor.