office of disability services
P.O. Drawer 7007
Greenville, NC 27835-7007
Phone: 252.493.7557
Fax: 252.321.4345
Application for Services
Educating and Empowering People for Success Revised: 5/20/16
office of disability services
P.O. Drawer 7007
Greenville, NC 27835-7007
Phone: 252.493.7557
Fax: 252.321.4345
¨ Transitional Studies
¨ Dual Enrollment
¨ Curriculum
¨ Continuing Education
Educating and Empowering People for Success Revised: 5/20/16
office of disability services
P.O. Drawer 7007
Greenville, NC 27835-7007
Phone: 252.493.7557
Fax: 252.321.4345
SECTION I: STUDENT INFORMATIONName: Student ID# ______
Date of Birth: Date of Application:
Month/Day/Year Month/Day/Year
Address: _____
Street and Number City State Zip Code
Educating and Empowering People for Success Revised: 5/20/16
office of disability services
P.O. Drawer 7007
Greenville, NC 27835-7007
Phone: 252.493.7557
Fax: 252.321.4345
¨ Home Phone: ______
¨ Cell Phone: ______
¨ Campus Email: ______
¨ Personal E-mail: ______
SECTION II. STUDENT STATUS AT TIME OF APPLICATION (SELECT ONE):¨ New PCC Student/Recent Graduate: School: Graduation Date:
¨ Previous PCC/ College Transfer Student (Name of School):
¨ GED / ADULT BASIC SKILLS / CONTINUING ED / EARLY COLLEGE
Accommodations you are requesting and/or have received elsewhere
SECTION III. DIAGNOSIS (SELECT ALL THAT APPLY):Educating and Empowering People for Success Revised: 5/20/16
office of disability services
P.O. Drawer 7007
Greenville, NC 27835-7007
Phone: 252.493.7557
Fax: 252.321.4345
Educating and Empowering People for Success Revised: 5/20/16
office of disability services
P.O. Drawer 7007
Greenville, NC 27835-7007
Phone: 252.493.7557
Fax: 252.321.4345
¨ ADD
¨ ADHD
¨ Autism
¨ Blind/ Visual Impairment
¨ Deaf/ Hard of Hearing
¨ Intellectual Disability
¨ Learning Disability
¨ Mobility
¨ Orthopedic Disorder
¨ Psychiatric
¨ Spinal Cord Injury
¨ Traumatic Brain Injury
Educating and Empowering People for Success Revised: 5/20/16
office of disability services
P.O. Drawer 7007
Greenville, NC 27835-7007
Phone: 252.493.7557
Fax: 252.321.4345
Educating and Empowering People for Success Revised: 5/20/16
office of disability services
P.O. Drawer 7007
Greenville, NC 27835-7007
Phone: 252.493.7557
Fax: 252.321.4345
Educating and Empowering People for Success Revised: 5/20/16
office of disability services
P.O. Drawer 7007
Greenville, NC 27835-7007
Phone: 252.493.7557
Fax: 252.321.4345
Other:
Educating and Empowering People for Success Revised: 5/20/16
office of disability services
P.O. Drawer 7007
Greenville, NC 27835-7007
Phone: 252.493.7557
Fax: 252.321.4345
SECTION IV. COMMUNITY INVOLVEMENT (SAME AS ON FILE):¨ Prior Military Service: Y / N Branch:
¨ Currently Employment: Y / N Employer:
Educating and Empowering People for Success Revised: 5/20/16
office of disability services
P.O. Drawer 7007
Greenville, NC 27835-7007
Phone: 252.493.7557
Fax: 252.321.4345
SECTION V: STUDENT CONSENTCONFIDENTIALITY STATEMENT
I understand the Office of Disability Services may discuss my educational situation with other professionals who have a legitimate need to know. The Office of Disability Services will not release confidential information to others without my completion of “ODS Consent for Release of Confidential of Information” the Family Educational Rights and Privacy Act of 1974, Release Form, ODS Permission to Disclose Records Form unless otherwise required by law.
Educating and Empowering People for Success Revised: 5/20/16
office of disability services
P.O. Drawer 7007
Greenville, NC 27835-7007
Phone: 252.493.7557
Fax: 252.321.4345
I acknowledge that I have read and understood the confidentiality statement.
Student Signature (and Parent/Guardian Signature if under age 18) Date
------FOR OFFICE USE ONLY------Comment:
ODS Staff has reviewed this form to ensure adequate information has been provided to initiate the application process.
ODS Staff Date
Educating and Empowering People for Success Revised: 5/20/16