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Accessibility Services Student Intake Form

Complete the accessibility intake form to initiate your accommodations request.

I. General Information

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example@example.com

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Undergraduate*
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Term*
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Military
Location*
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II. Disability Information

What is your diagnosed disability? (Check all that apply)*
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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*
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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*
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Note Taker*
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Reader*
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Scribe*
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Recorded lectures*
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Extended test time*
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Testing in a separate room*
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Audio textbooks/materials*
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Spell checker*
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Voice synthesizer*
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Word processor*
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Voice recognition software*
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Adapted keyboard*
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Franklin speller*
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CCTV*
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Talking calculator*
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Braille*
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Interpreter services*
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Phonic ear*
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Enlarged print materials*
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IV. Educational Background

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

Paying attention in class*
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Completing assignments*
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Taking notes*
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Memorizing*
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Managing time*
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Reading at a good rate of speed*
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Understanding what I read*
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Doing math calculations*
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Following directions*
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Spelling*
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Finishing tests on time*
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Putting thoughts into writing*
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Proofreading*
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Being motivated*
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Asking for help*
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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.

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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
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Contact Information
Please recheck your email address.
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Numbers only, between 10-15 digits.
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International numbers, start with a plus sign (+) & country code

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Additional Information
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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.

Please hold, we are submitting your application.