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DRC Student Registration Form
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Student Information
Please enter your information
First Name
(Required)
*
Last Name
(Required)
*
Middle Name
Student ID
(Required)
*
Email
(Required)
*
Please use your university issued email address
Student Phone Number
Are you a Health Science Student?
(Required)
*
AHS, CON, COM, DENT, JACSW, PHARM, SPH
Are you a Health Science Student?
Yes
Are you a Health Science Student?
no
Specific Accommodation Information
My diagnosed disability(ies) best fall into the following category(ies)
(Required)
*
Of the items selected above, which do you consider your primary disability.
(Required)
*
ASD Related / Developmental
Attention Deficit/Hyperactivity
Blind / Low Vision
Chronic Health
Cognitive
Communication
Deaf / Hard of Hearing
Learning
Mobility
Psychological
Temporary
Temporary (Injury)
Temporary (Pregnancy)
How does your disability affect you academically?
(Required)
*
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)