REGISTRATION FOR DISABILITY SUPPORT SERVICES
***To be filled out by the student***

Name: ________________________________     Sex: ________________    Age: ________

SS #: _____________________    Semester Enrolled: ________________    Box #: ________

Home Address: ___________________________    Home Phone: _____________________

                         ___________________________

Condition: Check all that apply and provide appropriate diagnostic paperwork
    [  ]  Learning Disability
    [  ]  Attention Deficit Disorder
    [  ]  Hearing Impairment
    [  ]  Visual Impairment
    [  ]  Neurological Impairment
    [  ]  Psychological/Emotional
    [  ]  Mobility Impairment/Wheelchair user
    [  ]  Medical Disability
Special Needs: Check all that apply
    [  ]  Housing
      [  ]  wheelchair accessibility - Please specify size of the wheelchair
      [  ]  handicap accessible restrooms in housing
      [  ]  air conditioning
      [  ]  accommodations for guide dog
      [  ]  other: ____________________
    [  ]  Academics
      [  ]  extra time for tests
      [  ]  copies of lecture notes
      [  ]  textbooks on audio tape
      [  ]  tests in separate room
      [  ]  readers or scribes
      [  ]  DSS or LD support/advisor
      [  ]  other: ____________________
    [  ]  Physical Plant
      [  ]  ramps
      [  ]  curb cuts
      [  ]  elevators
      [  ]  handicapped parking
      [  ]  handicap accessible restrooms
      [  ]  other: ____________________

Disability-related information is part of the official records of a student and protected by the Buckley Amendment. Information will not be released or discussed without student's consent except to College officials and faculty having legitimate educational interests. Student, please sign, thereby giving your consent for the Director to share this information with any other appropriate professionals as needed.

Student's Signature: _____________________________________    Date: ________________________

THIS FORM MUST BE ACCOMPANIED BY DIAGNOSTIC DATA AND RETURNED BY JUNE 1ST TO THE OFFICE FOR DISABILITY SUPPORT SERVICES, RANDOLPH-MACON COLLEGE, HIGGINS ACADEMIC CENTER, P.O. BOX 5005, ASHLAND, VA. 23005. Phone: (804) 752-7343.