Office of Accessibility Services

ACCESSIBILITY FORM APPLICATION

ACCESSIBILITY FORM APPLICATION


PERSONAL INFORMATION

Date Of Birth:
How do you travel to campus? (Check all that apply)?
Are you registered to vote?*

CONTACT INFORMATION


@jjay.cuny.edu
Can automated texting service contact you?*

HOW YOU GOT TO KNOW US

Agency Sponsorship (Check all that apply):
Are you a CUNY Leads student?

VETERAN INFORMATION

Are you a dependent of a veteran?
Have you ever been enlisted in any branch of the US military (active duty, veteran, National Guard, or Reserve)?
Did your military service include traumatic or highly stressful experiences, which continue to affect you?
Allowed file types word and pdf documents

ENROLLMENT/ACADEMIC STATUS

Are you an Undergraduate
Are you a Transfer Student

DISABILITY-RELATED INFORMATION


DISABILITY STATUS

Do you have a diagnosed and documented disability?*
Do you have multiple disabilities? :

If yes, please check all that apply:

ORTHOPEDIC
VISUAL
HEARING
Do you have a medical doctor or physician?

Please provide Pysician Contact Information

Do you have a therapist/psychiatrist?

Please provide Therapist Contact Information

Are you currently taking any medications to treat any disability or medical condition indicated above?

ASSISTIVE TECHNOLOGY & ALTERNATIVE TEXTBOOKS


What assistive technology/software/textbook formats do you use? (Check all that apply)

REQUESTING ACCOMMODATION FOR THE CLASSES BELOW

Please click "Add" below to include all the classes that you want accommodation for.

Course Code Section Day(s)/Time Instructor Room # Action



Please make sure to answer the capture above before submitting your application. Thank You.