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RICHLAND COLLEGE - DISABILITY SERVICES

NEW STUDENT INFORMATION FORM

Name:  
Student I.D:  
Date of Birth:  
E-Mail Address:  
Street Address:  
City:  
Zip Code:  
Phone(Home):  
Phone(Cell/Pager):  
Career Goal or Major:  
 
The following CONFIDENTIAL questions are for State/Federal statistical reporting only.
Check all your documented Disabilities below:
Asperger's Syndrome
Attention Deficit Disorder
Autistic Disorder
Learning Disability
Substance Abuse - Alcohol/Drug
Mental or Emotional Disorder
Low Academic Skills
Arthritis (Severe)
Asthma
Back Injury 		Visual Impairment
Burn
Cancer
Cerebral Palsy
Circulatory Problems
Deafness - 40 DB or more
Diabetes Mellitus - on Insulin
Epilepsy
Hearing Impairment
Brain Injury
Heart Condition 		Hypertension
Loss of Limb
Mobility Impairment
Multiple Sclerosis
Muscular Dystrophy
Other Disabilities
Sickle Cell Anemia
Speech Impairment
Spinal Cord Injury
Stroke
High School Graduate: Yes      No
GED: Yes      No
Sex: Female      Male
Other Colleges attended:
(1) (2) (3)
List any medications regularly taken regularly:
Are you a client of the Department of Assistive and Rehabilitative Services (DARS)?
Yes      No
If you answered YES to this question, please provide us with the name,
business address, and phone number of your DARS counselor:
Name:
Address, City, State:
Phone #:

Please take a few extra minutes to complete our On-Line Survey.