Physical Disabilities Services Application

Physical Disabilities Services Application

University Disability Support Services
University of Wyoming

This application is designed to gather information and determine eligibility for services, for students with disabilities that commonly affect physical functioning. Examples include mobility impairments, multiple sclerosis, cerebral palsy, chemical sensitivities, spinal cord injuries, cancer, AIDS, speech disorders, muscular dystrophy, hand function limitations, spina bifida, deaf/hard of hearing, or blind/low vision or other medical conditions. Please complete this form carefully and completely. If you have any questions regarding application items, contact the UDSS office.

If you need this application provided in an alternative format (e.g. taped, Braille, enlarged, on disk) or need assistance completing the application, contact the UDSS office.

General Information

Last Name:

First Name:

MI:

W Number:

DOB (mm/dd/yyyy):

Local Address:

Street:	City:	County:
State:	Zip:

Local Phone:

E-mail Address:

Permanent Address:

Street:	City:	County:
State:	Zip:	Permanent Phone:

Applying for Services for:

Semester: Fall Spring Summer

Year:

Who referred you to this office?

Academic Status:

Present Academic Status

Grad./Prof Student	College Junior	High School Student
One or More Bachelors	College Sophomore	GED Recipient
College Senior	College Freshman

High School Information

High School attending or attended:
What is/was your high school cumulative grade point average?	Year of Graduation

College Information:

Current cumulative grade point average:	Major (at UW):
Number of credits enrolled in this semester at UW:

College at UW:

Transfer Student Information
College transferred from:

Agency Affiliation
Do you work with:

Division of Vocational Rehabilitation? Yes No
If "Yes", please note the name/phone number of your counselor.

Name: Phone:
Services for the Visually Impaired? Yes No
If "Yes", please note the name/phone number of your counselor.

Name: Phone:
VA Vocational Rehabilitation? Yes No
If "Yes", please note the name/phone number of your counselor.

Name: Phone:

Disability Information

Physical disability (diagnosis):	Date of onset:
Please explain the diagnosis in more detail (anything that will help determine appropriate services):

To determine your eligibility for services from UDSS, this application must be accompanied by documentation which includes a diagnosis of the condition(s) you indicated and the extent to which the condition limits major life activities, such as learning, seeing, hearing, breathing, walking, speaking, caring for one's self, performing manual tasks, or working. It would also be helpful to receive copies of reports which reflect the kind of services or accommodations which have been provided or recommended to date. See enclosed Documentation Guidelines.

What accommodations do you anticipate needing to ensure equal access to UW's programs and services?

Printed materials in alternative format (e.g.electronic text, digitally recorded materials, etc.)

Test Taking Accommodations (e.g. extended time, 'scanned and read' exams, use of a computer, use of a scribe, enlarged tests, etc.)

Volunteer Note-takers

Orientation to Adapted Computers (e.g. screen readers, voice input systems, scan and read programs, screen enlargement software, alternative keyboards, etc.)

CD Player Loan (for use with RFB&D disks)

Assistive Listening Systems

Advocacy Services with instructors or other campus programs and/or staff

Handicapped Parking Referral

Accessible Transportation Referral

Written assignment (in class) accommodations

Oral class participation modifications

Other (please describe)

What type of referral information would be helpful to you?

Help in preparing papers

Word Processing Training

Study Skills Assistance

Tutoring Services

Getting more information about my disability, or diagnostic (testing) services

Other (please describe)

Do you plan to live on campus? Yes No
If yes, do you anticipate needing accommodations in your residence hall room or campus apartment (e.g. wheelchair accessibility, modifications to accommodate a hearing impairment, etc.)? If so, it is important that you apply for housing as early as possible. Be sure to state on your housing application what your disability is and what accommodations will be necessary. It is a good idea to visit campus in advance and ask Housing and Residence Life to show you an open room or apartment like one to which you would be assigned.

Applicants with Mobility Impairments
Do you use any mobility aids (e.g. wheelchair, power cart, crutches, braces, etc.)? Yes No

Do you have difficulty negotiating stairs? Yes No
If yes, please describe

Will you use a personal care attendant? Yes No
UDSS can assist students with locating attendants. UDSS is NOT, however, responsible for hiring, supervising, firing, paying, or scheduling attendants.

Applicants with Hearing Impairments
Do you require interpreter services? Yes No
If yes, do you prefer Sign or Oral interpreting? ASL SEE II Other

Do you have a TTY? Yes No

Do you use or would you be interested in information about assistive listening devices? Yes No

Do you need assistance with obtaining class notes? Yes No

Applicants with Visual Impairments
Do You:

I certify that the information on this application is accurate and complete to the best of my knowledge. I hereby authorize the University Disability Support Services program to obtain information from my UW educational record that may be pertinent to my participation in the program (i.e. high school and college transcripts, entrance test scores, semester and cumulative grades, etc.). I also authorize UDSS to communicate with other SEO or UW staff and with my UW instructors on matters pertinent to my disability and services needed through UDSS and SEO.

Full Name (first middle last):

Date (mm/dd/yyyy):

The information you provide on this form will not be shared with anyone outside the University of Wyoming without your permission. One agency that commonly shares information and services with UDSS is listed below. Please review the statement and sign it if you would permit us to share information with this agency.

I hereby request that the Division of Vocational Rehabilitation work with UDSS and authorize information-sharing between DVR and UDSS upon request of either agency.

Full Name (first middle last):

Date (mm/dd/yyyy):

_____________________________________________________

University Disability Support Services
Student Educational Opportunity
University of Wyoming
Box 3808, 1000 E. University Ave.
Room 330 Knight Hall
Laramie, WY 82071
Phone: (307)766-6189 | TTY: (307)766-3073 | Fax: (307)766-4010

Agriculture	Arts & Sciences	Business
Education	Engineering	Health Sciences
Law	Undecided

Need texts recorded? Yes No	Need test taking accommodations? Yes No
Use large print materials? Yes No	Use a guide dog? Yes No
Read or write Braille? Yes No	Have a recorder to tape classes? Yes No
Receive services from the State Services for the Visually Impaired? Yes No
Receive services from the regional library for the blind or physically handicapped (such as the Utah State Library for the Blind and Physically Handicapped)? Yes No
Have an individual membership with Recording for the Blind & Dyslexic? Yes No Number: Do you have any other disability or condition we should know about? Yes No If yes, please describe: