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Student Information

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First Name*:

Last Name*:

Middle Name:

Student ID*:

Email*:

Please use your university issued email address

Student Phone Number:

Are you a Health Science Student?*:

AHS, CON, COM, DENT, JACSW, PHARM, SPH

My diagnosed disability(ies) best fall into the following category(ies)*:

Of the items selected above, which do you consider your primary disability.*:

How does your disability affect you academically?*:

How does your disability affect student life in general, like housing and transportation?:

What, if any, accommodations have you received in the past?:

What additional information would you like DRC to know about your request?:

What accommodations are you requesting:

Upload supporting document(s):

Please contact the Disability Resource Center at 312-413-2183 to schedule an Intake Appointment with a Disability Specialist.