Disability Support Services
202 Holton Hall
Kansas State University
Manhattan, KS 66506
Phone: 785-532-6441
FAX: 785-532-6457
dss@k-state.edu

Application for Academic Accommodations and Services

Please complete the following fields to the best of your ability and click the submit button at the end of the form to submit your answers. The contents of this form will be sent to a professional in the Disability Support Services office, who will contact you to further discuss your application.

Demographic Information
First Name: Middle Initial: Last Name:

Date of Birth (Month/Day/Year):

Sex: Male Female

KSU E-mail:

Wildcat ID:

Permanent Address

Street Number and Name:

City: State: Zip:

Permanent Phone:

Current Address (if different from Permanent)

Street Number and Name:

City: State: Zip:

Current Phone:

Disability Information
Type of Disability

I am requesting academic accommodations because I am an individual with the following disability(ies) (please check all that apply):

Disabilities:

Attention Deficit Hyperactivity Disorder
Blind
Low Vision/Vision Impaired
Brain Injury
Chronic Health Related
Deaf
Hard of Hearing
Learning
Psychological
Mobility Impairment
Speech
Other:
What is your primary disability?

Educational Information
My Class Status

What best describes the courses you are enrolling in?
On Campus Only Online Only Both On Campus and Online

Major/Program enrolled in, if applicable:

Name of your advisor, if applicable:

Have you received academic accommodations from high school or another college or university?
Yes No

If yes, what accommodations did you receive?

Who referred you to this office:

Off Campus Agencies
Do you receive financial assistance from: State Vocational Rehabilitation/ SRS?
Yes No

Do you receive financial assistance from: VA/ Vocational Rehabilitation?
Yes No

If yes, what is the name and location of your counselor?

Name:

City:

State:

Accommodation Information
Does your disability require you to use an elevator?
Yes No

Does your disability require you to take medication?
Yes No

What accommodations, if any, did you receive in high school? (e.g., extra time on tests, copies of notes)

What accommodations, if any, did you receive for the ACT or other college entrance exams?

Have you used alternative text (audiobooks)?
Yes No

If so, are you enrolled in Talking Books?
Yes No

If so, are you enrolled in Recording for the Blind and Dyslexic?
Yes No

What kinds of accommodations or services do you feel would be most helpful to you at K-State.

What adaptive technology, if any, do you use? (e.g., specialized keyboard, screen reading software)

If you have problems with this form, please email dss@ksu.edu.

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Kansas State University
June 17, 2008