Application for Services from DSS

Disability Support Services
202 Holton Hall
Kansas State University
Manhattan, KS 66506
Phone: 785-532-6441
FAX: 785-532-6457
dss@k-state.edu

Application for Academic Accommodations and Services

Please complete the following fields to the best of your ability and click the submit button at the end of the form to submit your answers. The contents of this form will be sent to a professional in the Disability Support Services office, who will contact you to further discuss your application.

SHUTTLE INFORMATION

If you are only inquiring on setting up shuttle rides, please call DSS at 785-532-6441 between 8:00 a.m. and 5:00 p.m. Monday through Friday in order to register and set up rides.

Demographic Information
Date:

Name:

Date of Birth (Month/Day/Year):

Sex:

KSU E-mail:

Wildcat ID:

Local Address:

Permanent Address:

Day time phone number:

Evening phone number:

Disability Information
Type of Disability

I am requesting academic accommodations because I am an individual with the following disability(ies) (please check all that apply):

Disabilities:

Primary Disability

Secondary Disability

Third Disability

Other Disability:

Are you taking medication for a disability? If so, please describe how the medication affects you.

Educational Information
My Class Status

What best describes your location?

Major/Program enrolled in, if applicable:

Name of your advisor, if applicable:

Have you received academic accommodations from high school or another college or university?

If yes, what accommodations did you receive?

Who referred you to this office:

Off Campus Agencies
Do you receive financial assistance from: State Vocational Rehabilitation/ SRS?

Do you receive financial assistance from: VA/ Vocational Rehabilitation?

If yes, what is the name and location of your counselor?

Name:

City and State:

Accommodation Information
What kinds of accommodations or services do you feel would be most helpful to you at K-State.

What accommodations, if any, did you receive in high school? (e.g., extra time on tests, copies of notes)

What accommodations, if any, did you receive for the ACT or other college entrance exams?

Does your disability require you to use an elevator?

Have you used alternative text (audiobooks)?

If so, are you enrolled in Talking Books?

If so, are you enrolled in Recording for the Blind and Dyslexic?

If you have problems with this form, please email dss@ksu.edu.