K Number
Email Address
Academic Program
Are you

At which campus will you take classes?

Term and year ADA services will begin

Please describe your disability:

Please describe how your disability affects, limits or impacts you as a student:

If your disability creates a problem in class attendance, please explain why:

Have you previously received accommodations from a high school or college? (i.e. special education, resource room, accommodation services, etc.) Please give name of school(s) and years of attendance.

Who at Kirkwood have you talked to regarding your enrollemnt, classes or accommodations? (i.e. counselor, advisor)

What agencies in the community are you working with currently? (i.e. Vocational Rehabilitation, Abbe Center, Career Connections, psychologist or psychiatrist clinic)

Are you taking medication for the disability? Yes    No

Please describe how your medication(s) effect your performance as a student:

What kind of accommodations are you requesting for your classes at Kirkwood? (i.e. alternative test taking, reading of tests, books on CD, sign language interpreter, assistive technology, etc.)

By submitting this form I acknowledge that I am requesting accommodation services because of my disability and I am able to provide documentation of this disability.