Accessibility Center Intake Form * - indicates a required field.Legal Name* First Last Student Email* Student ID Phone*Semester* Do you have a documented disability?* Yes No Do you have current documentation?* Yes No Which campus do you attend?* Blackwood Campus Camden Campus Please indicate the nature of your disability: (check all that apply)* ADD/ADHD Learning Disability Blind/Low Vision Deaf or Hard of Hearing Speech and Language Impairment (Communication) Psychological (anxiety, depression, mood disorders, etc.) Neurological Medical Disorder Autism/Asperger’s Traumatic Brain Injury Mobility Impairment PTSD Other OtherTypes of requested services (please check all that apply): Extended Time (1.5) Recording Distraction-Free Testing Notetaker Reader/Scribe Assistive Technology Sign Language Interpreter C-Print Other Other types of requested servicesCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.
