Disability Services - Registration Form | Student Affairs

Contact Info

Andrea Pammer
Director of Disability Services
317 Colebank Hall
Phone: 304.367.4686
1.800.641.5678 Ext.8
Andrea.Pammer@fairmontstate.edu
Andrea.Pammer@pierpont.edu

Sorenson/VP/Video Phone Users:
IP 129.71.73.203

Amy Snively
Learning Coach
318 Colebank Hall
Phone: 304.367.4651
asnively@fairmontstate.edu
asnively@pierpont.edu

Amanda Barber
Assistive Technologies Specialist
319 Colebank Hall
Phone: 304.367.4073
abarber@fairmontstate.edu
abarber@pierpont.edu

FAX: 304.367.4406

EVACUATION GUIDE

EVACUATION CHECKLIST

EVAC CHAIR LOCATION

NOTICE UNDER THE AMERICANS WITH DISABILITIES ACT

1994 ADA Self-Evaluation and Transition Plan

GENERAL INFORMATION

Student's Name: *

Mailing Address

Mailing Address: *

Apartment Number:

City: *

State: *

Zipcode: *

Local Address

Local Address:

Apartment Number :

City:

State:

Zipcode:

Telephone (home): *

Telephone (other): *

Last 4 Digits of SSN: *

Birth Date: *

UCA:

What is a UCA? http://it.fairmontstate.edu/fsuwiki/index.php?title=IT_General_Tutorials_and_How_To%27s#What_is_a_UCA.3F

F Number:

Institution E-mail Address: *

ex. jdoe@students.fairmontstate.edu or jdoe@students.pierpont.edu

If you do not have an institution email address yet please enter your personal email.

Please read and initial the following (to be completed by the student)

Nature and Extent
It is the student's responsibility to voluntarily and confidentially disclose information regarding the nature and extent of their qualifying disability. The college does not assume responsibility for providing accommodations or services to students who have not identified themselves as having a qualifying disability.

Nature and Extent: * (initials)

Disclosure
I do hereby give my permission for the Disability Services Office to act as an advocate on my behalf with my instructors, vocational rehabilitation counselor, and other significant FSU/Pierpont Staff members. I understand that it is my responsibility to meet with each of my instructors to discuss and request accommodations.

Disclosure: * (initials)

Parent/Guardian's Name: *

Contact Information: *

How would you describe the help and support that you receive at home pertaining to school: *

What is your classification: *

If you selected other, please explain:

Intended Major: *

Advisor: *

Anticipated Graduation Date: *

MEDICAL BACKGROUND

What is your diagnosed disability: *

Describe your disability and how it affects your performance as a student: *

Other Disabilities: *

How do you cope with the limitations of your disability: *

Are you currently, or have you ever been, a client of West Virginia Department of Rehabilition: *

Check the tasks that you have DIFFICULTIES with:

	Difficult
Working in Groups
Communicates well with others
Paying attention in class
Completing assignments
Taking notes
Memorizing
Managing time
Reading comprehension
Doing math calculations
Doing math word problems
Following directions
Spelling
Finishing tests on time
Putting thoughts into writing
Proofreading
Being motivated

Did you receive accommodations in high school: *

Have you received tutoring: *

If yes, please list what subjects:

Have you ever been trained on assistive reading software: *

List any other assistive technology you have been trained on:

How would you rank your study habits?: *

Have you been taught how to study: *

How much time do you usually study per day: *

Check those accommodations that apply to you:

	Have used
Tutoring
Testing accommodations (extended time, separate quiet place, reader, scribe)
Note taking assistance
Books in alternate format (Read aloud, Braille, Large print, etc.)
Enlarged text
Braille
Screen reading software
Magnification software
Speech recognition software
Transcribing
Record Lectures
Sign Language Interpreter
Scribe
Word processor
Adapted keyboard
CCTV/V-Tek
Talking calculator
Assistive Listening Device

Physical accessibility assistance (please describe): *

Housing accommodations (please describe): *

Other (please list): *

Information shared with The Office of Disability Services will be kept confidential unless you authorize a release and exchange of specified information. Completion of this form does not guarantee academic accommodations and it is your responsibility to schedule an intake with our office to discuss the services and/or academic accommodations available. You MUST provide professional documentation to support your disability in order to qualify for academic accommodations. Accommodations can be provided only after these conditions are met. It is also your responsibility to contact instructors prior to each semester. This form is to be completed in consultation with the staff of the Office of Disability Services.

By submitting this form, you are acknowledging that all information is accurate.: *

I acknowlege all information is correct and accurate

Person completing form if other than self

Name:

Relationship:

(Must be completed by the student) I understand that if I am not enrolled in classes for four consecutive terms, my file and all its contents will be shredded.

Student Initials: *

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