Student Intake Disclosure Form

STUDENT CONTACT INFORMATION

First Name*

Last Name*

Phone*

Email Address*

Street Address*

City*

Zip Code*

BASIC STUDENT INFORMATION:

Student ID#

Date of Birth*

Gender*

Male Female

High School Graduate?*

Yes No

GED Completion?*

Yes No

Military Service/Veteran?*

Yes No

Previous College Attendance?*

Yes No

DISABILITY DISCLOSURE: (check all that apply to you)

If Other

DISABILITY DOCUMENTATION:

Military Service/Veteran?*

Yes No

Has your disability been professionally diagnosed or evaluated?*

Yes No

Can you provide us with documentation from a professional (such as a diagnosis with functional limitations listed, an IEP from high school, psycho-educational testing results, audiogram etc.)?*

Yes No

If yes, bring it with you to your intake appointment.

EMERGENCY PROCEDURES:

Does your disability affect you in an emergency situation? (such as fire alarms, severe weather sheltering, shelter in place, evacuation, etc.)*

Yes No

In case of emergencies, can you hear alarm signals and instructions?

Yes No

In case of emergencies, could you walk to the outer drive on campus?

Yes No

In case of emergencies, can you take stairs to get to safe locations?

Yes No

In case of emergencies, would you need any other special assistance?

Yes No

If yes, what would that be?

PERMISSIONS STATEMENT:

By typing my name into the field below,

I authorize the office of Student Accessibility and Support at Oklahoma City Community College to share pertinent information relating to my needs for accommodations/academic adjustments with the appropriate faculty and staff at Oklahoma City Community College.I acknowledge that this information will typically be shared automatically through online class rosters for the courses I am registered in.If greater details are required, an email or phone conversation concerning those details may also take place.

I further acknowledge that it is my responsibility to discuss these accommodations/academic adjustments with each of my instructors to get them implemented in those classes each semester.

Permission Statement Acknowledgement (type full name)

YOUR INTAKE INTERVIEW APPOINTMENT:

Once you have completed this form you need to schedule an appointment to meet with a member of the Student Accessibility and Support staff for your disability intake interview.You can stop by in person with this form (and any pertinent documentation) or call the Student Accessibility and Support office at 682-7520 to schedule the appointment.

How would you like to meet?*

In person Zoom meeting via Telephone