Accessibility Intake Form

APPOINTMENT DATE: (Call 719-502-3333 to schedule)

I understand that PPCC is not obligated to continue accommodations that have not been reviewed by this office. (INITIAL BELOW) Required

Are you a New or Returning student to Accessibility Services? Required

FULL NAME : (Last, First) Required

S Number

Student Email Required

Phone Number Required

Birth Date (mm/dd/yyyy) Required

Gender Identification (ex., Female, Male, They, Ze/Hir) Required

Disability (identified or diagnosed). Please check all that apply. Required

*Other Health Condition OR Temporary Disability (specify)

Please list any prescription, over-the-counter, and/ or alternative medication(s) you are taking at this time.

Have you received accommodations in school before? Required

K-12 Education (IEP/504 plan, resource room)

Other college or university

Not Applicable

Please check your STUDENT STATUS: Required

Military Veteran

Active Duty Military

Military Dependent (family member)

Currently enrolled in High School and College

Not Applicable

How did you find out about us? (check all that apply) Required

Accommodation Request