Student With Disabilities Information Form

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SERVICES FOR STUDENTS
WITH DISABILITIES
Student Information Form
Last Name ___________________________ First Name _________________________
Street Address ___________________________________________________________
City
State
Zip Code _____________
 Home
 Home
 Mobile
 Mobile
Daytime Phone ______________________
Evening Phone ___________________
 Work
 Work
 Permission to leave detailed message
 Permission to leave detailed message
E-mail Address __________________________________________________________
Emergency Contact _______________________ Emergency Phone _______________
M  F 
Student Identification Number _________________________________
Please check all that apply:
 Deaf
 Orthopedic condition
Click to Submit Form
 Hard of hearing
 Medical Condition
____ Renal disease
 Mobility
____ Diabetes
_____ Limited gait
____ Lupus
_____ Limited range of motion
____ CFS
_____ Paraplegic
____ HIV/AIDS
_____ Quadriplegic
____ Fibromyalgia
_____ Other spinal cord injury
____ Allergy
_____ Other __________________________________________________
____ Other ______________________
 Speech or Language Disorder
 Neurological/Nervous System
 Diagnosed Learning Disability
____ Cerebral Palsy
 ADD/ADHD
____ Seizures
 Blind
____ Multiple Sclerosis
 Visual Disorder
____ Tourette Syndrome
____ Parkinson’s
 Chronic/Acute Health
____ Peripheral Neuropathies
_____ Cancer
____ Muscular Dystrophy
_____ Cardiovascular
____ Other ______________________
_____ Pulmonary
_____ Other __________________________________________________
 Psychological/Emotional
Diagnosis___________________
 Acquired Brain Injury
 Other__________________________
 Developmental Disability
(please specify)
16101 Greenwood Ave North • Shoreline, WA 98133-5696 • (206) 546-4545 •
Shoreline Community College does not discriminate on the basis of race, color, national origin, sex, disability, or age in its program and activities. The
following person or persons has/have been designated to handle inquiries regarding the non-discrimination policies:
Dr, Tonya Drake/Vice President Student Success, Rm: 5202, 206-546-6910, tdrake@shoreline.edu

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