EmailMe Form - Voluntary Declaration of Disability

This form is to be completed only if you have a disability and are requesting academic accommodations. The information on this form is confidential and will only be released to those individuals responsible for providing assistance to students with disabilities.

Please check the area(s) that best describe(s) your disability: *

Name *

First MI Last

Preferred Name:

ABAC ID Number *

Semester (Fall, Spring, or Summer) and Year you plan to begin attending ABAC: *

Your Answer

Date of Birth *

MM / DD / YYYY

Cell Number

### - ### - ####

Home Phone

### - ### - ####

ABAC Email *

Campus or Site Location *

Student Status *

First-year (beginning) student

Returning Student

Transfer/transient

Local Addres:

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

The documentation that you provide to Accommodation & Disability Services may be shared with the Regents Center for Learning Disorders for review in consideration of academic accommodations requested. Please type your name if you consent to the release of your information. By typing your name, you are confirming that you are the student completing this form. Student signature: *

Your Name