Student Disability Services Information Form Columbus Technical College ID Number*Full Name First Middle Last Suffix Full Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code CountyPhoneMajorEmail AdvisorAgency CounselorUntitledNew StudentReturningUntitledNew StudentReturningSexMaleFemaleDate of Birth (example: 1/1/2000) Date Format: MM slash DD slash YYYY Educational Level (example: HS)UntitledBlackWhiteHispanicIndianAsianOtherFinancial Sponsor (check all that apply) Pell Hope VR VA/VR (DAV) WIA Scholarship Workers Comp Paying your own way Note: if you deny having a disability, Student Disability Services will be unable to assist you. You must list your disability if you require special accommodations.List your disability (Please be specific)Do you have professional documentation of your disability?YesNoOther source (please list)Will you require special accommodations?YesNoWhat accommodations requested?With reasonable accommodations or adjustments, will you be able to receive training as dictated by the State standards and directed by the policies and procedures of the institution?YesNoAre you presently taking any doctor-prescribed medication, due to your disability or otherwise?YesNoWill any of the above medication interfere with your ability to reasonably function?YesNoBlind or Visually Impaired Students: How will you prefer your reading materials? Audio CD Braille Level 1 Braille Level 2 If you are selecting the CIS program, have you had any computer literacy trainingYesNoContact PersonRelationship to StudentDaytime TelephoneEvening TelephoneAlternate Phone NumberSecond Contact PersonSecond Contact's Relationship to StudentDaytime TelephoneAlternate Phone NumberAlternate Phone NumberInstructor(s)Administrator(s)OthersCAPTCHA Author CTC Web Admin