Disability Services - Registration Form

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Turley Student Services Center
Suite 316
Phone: (304) 333-3661
TTY: (304) 367-4906
access@fairmontstate.edu

Andrea Pammer, MA
Licensed Psychologist
Director of Counseling & Disability Services
Turley Student Services Center
Room 316G
Phone: (304) 367-4686
1-800-641-5678 Ext.8
Andrea.Pammer@FairmontState.edu

Amy Snively, MS, MEd
Academic Coach/Program Specialist
Turley Student Services Center
Room 316C
Phone: (304) 367-4651
asnively@fairmontstate.edu

Video Phone Users:
IP 129.71.73.203

Steps to Register with Fairmont State University Disability Services

Complete the registration form below.
Call 304-333-3661 to schedule an appointment for an intake, if you do not hear from us within 2-3 buisness days. There are times when we experience intermittent delays in email corresponce, so this will ensure prompt attention to your request.
Provide official documentation of your disability at the initial intake (appropriate documentation is one of the following: a letter from your health care provider that is typed, on letterhead, dated and contains all the information in this sample letter; a complete evaluation report; an IEP or 504 Plan from your school; or documentation from a previous institution of higher education). Provisional accommodations may be granted for no longer than one semester without complete documentation as long as as the evidence presented supports the presence of a disability. Students are required to obtain sufficient documentation for continuation of services beyond one semester.
Contact your local Division of Rehabilitation Services for additional resources. In West Virginia, call toll free 1-800-642-8207.

If you have questions regarding the registration process, please call 304-333-3661.

Pierpont Community & Technical College students should visit the Pierpont Community & Technical College website to register for disability services.

If you live on campus and your diagnosis is important for residence life staff to be aware of (e.g. diabetes, seizure disorder, etc.) for safety reasons, but you are not requesting housing accommodations, please email Residence Life.

Registration Form

Student's Name *

Student ID / F Number

Birth Date *

Month

Day

Year

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.

Personal E-mail Address

Telephone (home)

Telephone (cell) *

Preferred contact method *

Intended Major *

Anticipated Graduation Date

Home Address

Mailing Address

Apartment Number

City

State

Zip Code

Local Address

Apartment Number

City

State

Zip Code

Are you a Veteran?

Yes

Are you a client of WV Division of Rehabilitation Services?

Yes

Diagnosis *

Please describe your disability and how it affects you as a student. *

Please describe any accommodations you had in the past.

Do you have difficulty with the following tasks?

	Yes	No
Caring for yourself	Caring for yourself - Yes	Caring for yourself - No
Hearing	Hearing - Yes	Hearing - No
Breathing	Breathing - Yes	Breathing - No
Seeing	Seeing - Yes	Seeing - No
Talking	Talking - Yes	Talking - No
Walking/Standing	Walking/Standing - Yes	Walking/Standing - No
Lifting/Carrying	Lifting/Carrying - Yes	Lifting/Carrying - No
Completing Assignments	Completing Assignments - Yes	Completing Assignments - No
Managing time	Managing time - Yes	Managing time - No
Memorizing	Memorizing - Yes	Memorizing - No
Paying attention in class	Paying attention in class - Yes	Paying attention in class - No
Reading at a good rate	Reading at a good rate - Yes	Reading at a good rate - No
Understanding what I read	Understanding what I read - Yes	Understanding what I read - No
Taking Notes	Taking Notes - Yes	Taking Notes - No
Doing math calculations	Doing math calculations - Yes	Doing math calculations - No
Doing math word problems	Doing math word problems - Yes	Doing math word problems - No
Following directions	Following directions - Yes	Following directions - No
Spelling	Spelling - Yes	Spelling - No
Finishing tests on time	Finishing tests on time - Yes	Finishing tests on time - No
Putting thoughts into writing	Putting thoughts into writing - Yes	Putting thoughts into writing - No
Getting organized	Getting organized - Yes	Getting organized - No
Proofreading	Proofreading - Yes	Proofreading - No
Being motivated	Being motivated - Yes	Being motivated - No
Staying on task	Staying on task - Yes	Staying on task - No
Sleeping	Sleeping - Yes	Sleeping - No

Please describe any physical access assistance that you may require.

Please list and/or describe the academic accommodations you are requesting. *

Please describe any housing accommodations you are requesting. Students requesting housing accommodations also need to complete a Housing Application, which can be found by logging onto myFairmontState and clicking on the housing icon.

Please describe any physical assistance or accommodations you are requesting. Students requesting housing accommodations also need to complete a Housing Application, which can be found by logging onto myFairmontState and clicking on the housing icon. Students requesting parking assistance must obtain a Campus Disabled Parking Permit from Student Services.

Please include additional information you would like to share.

You can attach documentation here, or bring it with you to your initial appointment.

Files must be less than 8 MB.
Allowed file types: gif jpg jpeg png bmp tif txt rtf html pdf doc docx ppt pptx xls xlsx xml.

Please submit your completed registration form below. Completion of this form alone does not warrant accommodations. Through individual consultation, accommodation, and service, we engage in an interactive process with each student to understand how his or her disability intersects with the institutional environment, and how accommodations would reduce barriers and not fundamentally alter essential components of the course, program, activity, or experience. If you are not contacted within 2-3 business days, please call 304-333-3661 to schedule an intake. As mentioned above, there are times when we experience intermittent delays in email correspondence, so this will ensure promt attention to your request for services. Thank you!

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