Center for Accessibility and Disability Resources Application

Center for Accessibility and Disability Resources Application
Student Intake Form

Please answer the following questions to help us better determine your needs. Your responses are confidential.

Requests for accommodations may require the submission of appropriate documentation. Please see Documentation Guidelines for specific information.

You must make an appointment for an intake interview to discuss your needs.

If you are requesting accommodations for the College placement testing be sure to link with the Center for Accessibility and Disability Resources prior to testing.

Please allow sufficient time to process an application with our office. Generally, 2 to 4 weeks ahead of the start of a semester is required.
Today’s Date:*

MonthDayYear
Date
Personal Information
Full Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Middlesex College ID #:*
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Email Address*
example@example.com
Home Phone Number:*
Cell Phone Number:*
Current Status at Middlesex College:*

Just ApplyingAlready Attending
Are you currently enrolled in the Dual Enrollment Program with Middlesex College?*

YesNo
What high school do you currently attend?*
Are you a visiting student from another college or university?*

YesNo
What college or university do you currently attend?*
Number of Credits*
Major*
Are you working with the Division of Vocational Rehabilitation?*

YesNo
Name of DVR Counselor/Commission for the Blind Counselor*

First NameLast Name
If yes, name of DVR Counselor/Commission for the Blind Counselor:*

Academic Information
Were you classified in Special Education in High School?*

YesNo
What was the classification?*
If you are currently taking College level classes please describe any academic difficulties you are having:*

Assistive Technology Assessment
Have you ever been evaluated to use any assistive technology?*

YesNo
What assistive technology was recommended for you?
Do you currently use this technology?*

YesNo
Did you use any assistive technology in High School?*

YesNo
The information contained in this form is true and accurate to the best of my knowledge.
Signature*
Date*

MonthDayYear
Date
Should be Empty:

Center for Accessibility and Disability Resources Application

Student Intake Form

Personal Information

Reason for Referral

Requests:

Academic Information

Medical History

Psychological History

Assistive Technology Assessment