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Student Disability Disclosure Form
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Student Information
First Name
Required
*
Last Name
Required
*
Middle Name
Preferred name
Pronouns
Student ID
Required
*
Include any leading zeroes (ex: 0000000)
WCU Email
Required
*
Please use your university issued email address
Phone Number
Required
*
Current academic standing
First Year
Sophomore
Junior
Senior
Masters
Doctoral
Other
Anticipated graduation date
Are you the first person in your family to attend college?
Are you the first person in your family to attend college?
Yes
Are you the first person in your family to attend college?
No
Are you in the military or are you a veteran?
Are you in the military or are you a veteran?
Yes
Are you in the military or are you a veteran?
No
Military status
Civilian/Non-Dependent
Dependent
Active Duty
Guard/Reserve
Veteran
Retired
None
Are you a non-degree student?
Are you a non-degree student?
Yes
Are you a non-degree student?
No
Are you a transfer student?
Are you a transfer student?
Yes
Are you a transfer student?
No
Name of institution from which you transferred
Semester/Year of transfer
Are you attending WCU for summer session(s) only?
Are you attending WCU for summer session(s) only?
Yes
Are you attending WCU for summer session(s) only?
No
What is your home institution?
Do you live on campus?
Do you live on campus?
Yes
Do you live on campus?
No
Where do you live on campus?
Where do you live on campus?
USH Affiliated Housing
Where do you live on campus?
WCU Owned Housing
WCU Managed Housing
Goshen Hall
Tyson Hall
College Arms Apartments
South Campus Apartments
Schmidt Hall
Killinger Hall
I have not been asssigned yet
USH Affiliated Campus Address
If you are looking for housing accommodations but live in USH Affiliated housing please note that the OEA does not handle USH Affiliated housing accommodations. You will need to contact USH Affiliated housing directly via phone (610) 430-4988 or by email: leasing@ushcommunities.org.
Allegheny Hall
University Hall
East Village Apartments
Village Apartments
I have not been asssigned yet
Commonwealth Hall
Brandywine Hall
Home Address
Disability/Diagnostic Information
Select your disability/disabilities
Choose all that apply
[select]
ADD/ADHD
Autism
Deaf or Hard of Hearing
Emotional/psychological impairment
Learning disabled
Medical/health impairment
Physical/mobility impairment (ambulatory)
Physical/mobility impairment (wheelchair)
Traumatic brain injury
Visual impairment
Other
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If other, please specify
Describe how your disability affects you both outside and inside the classroom, including exam and studying situations
Check any of the Life Activities listed below that you believe are affected as a result of your diagnosed condition(s)
Choose all that apply
[select]
Attending class
Breathing
Calculating
Caring for yourself
Concentrating
Eating
Hearing
Interacting with others
Learning
Lifting/carrying
Listening
Making/keeping appointments
Managing distractions
Meeting deadlines
Memorizing
Organization
Performing manual tasks
Reaching
Reading
Seeing
Sitting
Sleeping
Spelling
Stress management
Taking exams
Talking
Thinking
Walking/standing
Working
Writing
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List any other condition(s) affecting school that you would like to discuss
Have you received accommodations previously?
Have you received accommodations previously?
Yes
Have you received accommodations previously?
No
Accommodation Information
What accommodations have you previously received?
What accommodation(s) are you requesting?
Upload supporting document(s)
Required
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Drop files here to upload
Upload File
Agreement
Required
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By signing below, I am certifying that I am, in fact, the student requesting accommodations through The Office of Educational Accessibility (OEA).