Empire State College Disability Delcaration and Request ...
Center: ________________________ Date: _____________ ID: ____________________
Student Name: _____________________________________________________________
Address:________________________________________________________________________________________________________________________________________________________________
Primary Phone: ________________________ Additional phone: ___________________________
Email: (Required) _____________________________________________________________________
Area of Study: ______________________________ Primary Mentor: ______________________
Please check areas that apply:
___ Veteran ___ ACCES-VR (formerly VESID) ___ CBVH
All SUNY colleges and universities are required to offer students with disabilities the opportunity to register to vote. If you are not registered to vote where you live now, would you like to apply to register here today?
__ Yes __ No, because I choose not to register
__ I am already registered at my current address
__ I asked for and received a mail registration form
Please describe your disability: __________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
When were you diagnosed with this disability? _____________________________________________
Who diagnosed this disability? __________________________________________________________
If it is requested, can you provide current documentation of this disability?*
What accommodations are you requesting?
*The following accommodations require documentation. If requesting, please indicate below:
Alternative Textbooks ADA Part-Time TAP
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For office use only:
____ Approved ___ Denied ____ More information requested ____ Documentation rec’d
DX codes:_______________________ AC codes: __________________________________ NVRA code: _____
Decision by: ___________________________________
Entered: EMER: ___ Email sent (student, disability rep, primary mentor): _____________
Date: ________________ Staff initials: _________________
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