Accessibility Services Student Intake Form

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 #

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

Fax #

City or County

Counselor's Name

2. Agency Name

Phone #

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

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

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

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Reader* Have Used Have Not Used Very Helpful Not Helpful

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Scribe* Have Used Have Not Used Very Helpful Not Helpful

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

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

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

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

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

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

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

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

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

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

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CCTV* Have Used Have Not Used Very Helpful Not Helpful

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

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Braille* Have Used Have Not Used Very Helpful Not Helpful

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

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

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

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IV. Educational Background

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

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.

Accessibility Services Student Intake Form

Complete the accessibility intake form to initiate your accommodations request.

I. General Information

II. Disability Information

Agency Information

III. Support Services/Academic Adjustments

IV. Educational Background