ACCESSIBILITY SERVICES APPLICATION FORM

ACCESSIBILITY FORM APPLICATION

PERSONAL INFORMATION

First Name:*

MI:

Last Name:*

Date Of Birth:

Month*

Day:*

Year:*

EMPLID:

Gender:*

Other Gender:*

How do you travel to campus? (Check all that apply)?

Access-A-Ride

MTA: Bus/Subway

Walk

Other

Please type other transportation method:

Are you registered to vote?*

Yes

CONTACT INFORMATION

Your Address(Street Name)*

Apartment Number

Zip Code*

City*

State*

Home Phone #

Enter Your John Jay User Name*

@jjay.cuny.edu

Alternative Email address

Emergency Contact Name*

Emergency Contact Phone*

Can automated texting service contact you?*

Yes

Cell Phone Number for appointment reminders

HOW YOU GOT TO KNOW US

Who referred you to the Office of Accessibility Services?

Agency Sponsorship (Check all that apply):

ACCES-VR

CBVH

SEEK

Other

Please provide ACCES-VR, CBVH, SEEK, VA or OTHER counselor name & contact information:

Full Name

Office Phone

Cell Phone

Are you a CUNY Leads student?

Yes

VETERAN INFORMATION

Are you a dependent of a veteran?

Yes

Have you ever been enlisted in any branch of the US military (active duty, veteran, National Guard, or Reserve)?

Yes

Did your military service include traumatic or highly stressful experiences, which continue to affect you?

Yes

Yes (please describe below or attach a documented report): Click to attach supporting document Allowed file types word and pdf documents

ENROLLMENT/ACADEMIC STATUS

Registration Status*

Major*

Current GPA*

Are you an Undergraduate

Yes

Please select your undergraduate Level:(e.g Senior,Sophomore)

Are you a Transfer Student

Yes

Please type your transfer Institution Name:

Degree Type:*

Number Of Credits Completed

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
Course Code	Course Section	Day(s)/Time	Instructor	Room Number

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

Office of Accessibility Services

ACCESSIBILITY FORM APPLICATION

ACCESSIBILITY FORM APPLICATION

PERSONAL INFORMATION

CONTACT INFORMATION

HOW YOU GOT TO KNOW US

VETERAN INFORMATION

ENROLLMENT/ACADEMIC STATUS

DISABILITY-RELATED INFORMATION

DISABILITY STATUS

ASSISTIVE TECHNOLOGY & ALTERNATIVE TEXTBOOKS

REQUESTING ACCOMMODATION FOR THE CLASSES BELOW

Your Application is been submitted to the Office of Accessibility Services.