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

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

Accommodation Request