Student Disability Services
VC, Room 2-272
Phone: 646-312-4590
STUDENT INFORMATION: If you need assistance to complete this form, please ask
CUNYFirst ID#: Date:
Major:______
__Zicklin School of Business __Weissman School of Arts & Sciences ___Marxe School of Public & International Affairs
___ Undergraduate ___ Graduate Program ___ Freshman ___ Transfer
Name : ______
LAST NAME FIRST NAME MI
Mailing Address:
STREET (APT #) City State Zip Code
Cell Number: ( )
Ethnicity: Date of Birth: ______
Email Address: ______
Gender: ___ Male ___ Female ___ Transgender ___ Prefer not to answer
How did you find out about Student Disability Services? ______
What is your disability?
Is your disability temporary? ___ Yes ___ No
EDUCATION
High School:
College: ______
Did you have an Individualized Education Plan (IEP) in High School? ___ Yes ___ No
Are you the first person in your household to attend college? ___ Yes ___ No ___ I don’t know
EMPLOYMENT STATUS
Are you currently working? ___ Yes ___ No If yes, how many hours do you work per week?
CAREER GOALS
Are you interested in discussing employment opportunities and career-development options with a CUNY LEADS Advisor? ___ Yes ___ No
SUPPORTS AND SERVICES
Please share (if you wish) whether or not you are associated with any of the following:
___ New York State ACCES-VR. Your Counselor:
___ CBVH (Commission for the Blind and Visually Handicapped) Your Counselor:
___ Veterans Benefits and Services
___ Other:______
LIFE ACTIVITIES AFFECTED BY YOUR DISABILITY:
The following is a list of some major life activities. Place an “X” next to each activity you believe is affected by your disability.
Do you take medication that relates to your disability? ___ Yes ___ No
Are there side effects from this medication that may affect your classroom performance? ___ Yes ___ No
Assistive DEVICES and Assistive TECHNOLOGY
Do you currently use any of the following Assistive Devices or Assistive Technology:
___ Wheelchair ___ Digital Recorder
___ Cane ___ FM Unit
___ ScreenReader ___ Speech Recognition Software
___ Tablet ___ MAC Computer
___ I communicate by sign language only ___ Hearing aids
___ LiveScribe Recording Pen
___ Other
ACCOMMODATION REQUEST
What accommodations are you requesting at Baruch College?
1 ______
2.______
3.______
DOCUMENTATION
When this application is completed, and you have provided documentation of your disability, a counselor will schedule an interview with you to review your Accommodation Request.
VOTER REGISTRATION
This office is a National Voter Registration Act Voter Registration Site. You will be offered the opportunity to register to vote when you register for services. You may accept or refuse. Thank you for helping us to comply with the law.
Based on our interview today, the following are your Academic Adjustments/Accommodations:
______
Counselor Signature and Date: ______
STUDENT CERTIFICATION: Please do not sign until you have met with the Counselor. Thank you.
I understood the questions on this application and have answered them truthfully. The accommodations offered to me in this setting, or the reasons I am not receiving accommodations in this setting, have been clearly explained to me.
I provided documentation of my disability which was reviewed and was returned to me.
I understand that Student Disability Services will not contact my professors to inform them that I am registered with this office. It is my responsibility as a student to do so.
If an issue arises that relates to accommodations in the classroom, I should contact this office for assistance.
Student’s Signature: Date:
Counselor’s Signature: Date:
REVISED 10-12-2016 - Page 4 of 4