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Disability Support Services Intake Form
*
indicates a required field
Student Information
Please complete the form below. Please note that it is required to submit documentation as part of the registration process. If you do not have documentation to upload with this form, please submit to dss@ju.edu
First Name
Required
*
Last Name
Required
*
Middle Name
Student ID
Required
*
Please use your university issued student ID.
Email
Required
*
Please use your university issued email address
Phone Number
Required
*
Expected Graduation Date
Required
*
General Information
Are you a current JU student?
Required
*
If you select "no", please be advised that this process cannot continue through this system, but we will be happy to assist you. Just contact us at dss@ju.edu
Are you a current JU student?
Yes
Are you a current JU student?
No
Is this a Temporary Request?
Required
*
Is this a Temporary Request?
Yes
Is this a Temporary Request?
No
Request Type?
Please select a type based on need
Request Type?
Temporary
Request Type?
Sports Related Injury
Request Type?
DSS Parking Pass
Request Type?
Remote Learning Need
Student Class
Student Class
F
Student Class
So
Student Class
Jr
Student Class
Sr
Student Class
Gr
First semester you need accommodations
Example: Spring 2023
Your enrollment semester/year will be
Required
*
Example: Spring 2023
Have you previously received accommodations and services from JU’s DSS?
Have you previously received accommodations and services from JU’s DSS?
Yes
Have you previously received accommodations and services from JU’s DSS?
No
When did you receive services?
Please note that if you have received services after Fall 2022, you do not need to complete this form. Please contact dss@ju.edu for more information.
What is your disability category?
Required
*
Have you previously received accommodations from another school?
Have you previously received accommodations from another school?
Yes
Have you previously received accommodations from another school?
No
Did you receive accommodations in high school?
Did you receive accommodations in high school?
Yes
Did you receive accommodations in high school?
No
Name of High School
Did you receive services at a different college?
Did you receive services at a different college?
Yes
Did you receive services at a different college?
No
Name of College
What types of accommodations have you received in the past?
Check all that apply.
[select]
Extended time on exams/quizzes
Alternative testing environment
Use of calculator for in-class assignments
Use of tape recorder/tablet to record lectures
Preferential seating in classroom
Additional breaks during extended classes
Access to class notes through professor
Assistance in identifying student to share notes
Use of lap top for in-class assignments
Other
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What accommodation(s) are you requesting?
Upload supporting document(s)
Please review our
documentation guidelines
.
Documentation
Required
*
If no documentation is attached, your request will stay "pending" until the documentation has been received. If you have any questions, please reach out to us.
Documentation
I uploaded documentation with this form.
Documentation
I will submit my documentation at a later time.
Documentation
I do not have documentation.
Document Information
Document Title
Required
*
File
Required
*
Maximum file size: 10240kb
Description