Disability Services - Registration Form | Turley Student Services Center

Please complete the form below to register for disability services.

GENERAL INFORMATION

Student's Name *

Mailing Address

Apartment Number

City

State

Zipcode

Local Address

Apartment Number

City

State

Zipcode

Telephone (home)

Telephone (other) *

Last 4 Digits of SSN

Birth Date

Month

Day

Year

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.

If you selected other, please explain

Intended Major

Advisor

Anticipated Graduation Date

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Contact Info

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

Turley Student Services Center | Fairmont State University

Disability Services - Registration Form

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