Phillips Community College
Of the University of Arkansas
Application for Services
For Disabled Students

Advisement and Student Success

BASIC INFORMATION:
Last name                                   First name:                    Birth date:                     SSN:                           Address:                                                 City:                             State:                Zip:                             Home phone:                               TDD:                            Business phone:                         Hours:                       
In case of emergency, notify:                                         Relationship:                    Phone:                       
Today’s date:                                          Semester of enrollment at PCCUA:                                         
PIN#:                 Rehabilitation Services counselor:                                             Phone:                       
EDUCATION:
High school graduate:                                GED certificate:                              
Date:                          Current year in college:                 Sophomore                  Freshman                     Not currently enrolled
Other colleges attended:                                       Last date of enrollment:                                   ABOUT YOUR DISABILITY:
What is your disability/disabilities and how would you describe each disability:

Other disability information:                                                                                                                      

SERVICES REQUESTED:
When the Advisement Center mails information to you that is more than one page, would you like it on tape?                  ___yes             ___no
Do you have seizures?           ___yes             ___no
Type of health insurance:       ___Medicaid    ___Medicare    ___other          ___none
Do you use a wheelchair?     ___yes             ___no
   

CLASSROOM SERVICES
___taping lectures                                                    Would you like to use an individual
___front row seating                                                                 faculty memo?    ___yes           ___no
___help finding note takers                                                      
___interpreters
___clear view: lip-reading
___assisted listening device
___large print handouts
___visual media described
___physical assistance in labs
___wheelchair height tables
other                                             

 Do you give the Advisement Center coordinator permission to discuss your disability and accommodations with your instructors?       ___yes             ___no

If yes, please sign here: