Center For Learning - Student Data Sheet - Suny Sullivan printable pdf download

Center For Learning - Student Data Sheet - Suny Sullivan

SUNY Sullivan

DISABILITY REFERRAL

(Completion of this form is voluntary and optional)

Dear Student:

The Department of Learning and Student Development Services at SUNY Sullivan has been designated as

the office on campus for assisting students with disabilities. If you plan to request accommodations for a

physical and/or learning disability please complete and return this form as soon as possible. Information you

provide here is strictly voluntary and the provision of services is not dependent on completion of this form. The

information will be shared only with officials responsible for assisting you in meeting your needs.

Please check the appropriate responses:

1. Do you have a disability that substantially limits one or more major life activity?

Yes___________________No____________________

2. What is the nature of your disability? Please check all that apply:

Learning disability

Visual impairment

Mobility impairment

Hearing impairment

Other (please describe)______________________________________________________

3. What accommodations, including academic support, will you need as a student at SUNY Sullivan?

4. Will you be receiving assistance from any outside agencies? If so, please specify.

Please fill in the following information:

Name:

Phone # or Cell #:

Address:

I verify that this information is accurate: ________________________________________________________________________

Student Signature

date

Return form w/ your High School Individualized Educational Plan (IEP or 504) and/or other documentation to:

SUNY SULLIVAN

Department of Learning and Student Development

Attn: E.Howell

112 College Road

Loch Sheldrake, NY 12759

For more information contact: Eileen Howell @

ehowell@sunysullivan.edu

or call 845.434.5750 X4328

Center For Learning - Student Data Sheet - Suny Sullivan