Tel: 032) 626-1198
Fax: 032) 626-1199
www.sunykorea.ac.kr
Student Accessibility Services
Classroom Accommodations Application
Student Intake Form
Personal Information
Name:
Preferred Name:
Student ID#
DOB:
SBU Email
Alt. Email:
Cell Phone:
Alt. Phone:
Local Address
Permanent Address:
Major/Program:
Emergency Contact
Name:
Relationship:
Cell Phone:
Alt. Phone:
Academic Information
Freshman ☐ Sophomore ☐ Junior ☐ Senior ☐
Masters ☐ Doctoral ☐ Other ☐
Disability Information (Check all that apply)
☐ ADHD/ADD
☐ Mental Health Disability
☐ Allergy
☐ Mobility Impairment
☐ Autism Spectrum Disorder
☐ Neurological Condition
☐ Brain Injury/TBI
☐ Post-Traumatic Stress Disorder (PTSD)
☐ Deaf/Hard of Hearing
☐ Speech & Language Impairment
☐ Learning Disability
☐ Temporary (specify)
☐ Medical
☐ Visual Impairment
☐ Other (Please Specify
1
Student Accessibility Services
☎ 032-626-1198
Tel: 032) 626-1198
Fax: 032) 626-1199
www.sunykorea.ac.kr
Disability and Current Impact
Please describe how
your disability
currently impacts
you in academic
settings:
Please describe how
your disability
currently impacts
you in
Social/Personal
settings:
Accommodations:
What
accommodations
have you previously
used?
Please list the
accommodations
you are requesting
If applicable, please
list any adaptive
technology you will
be using
Signature
Date
You must submit this application along with your official diagnosis document* to Student
Accessibility Services (sas@sunykorea.ac.kr)
*Documentation should include: 1) Patient’s name; 2) Official diagnosis; 3) Procedures and Assessments used;
4) A description of symptoms or how the condition limits life activities; 5) A description of how the disability
interferes with academic life; 6) A statement of recommended accommodations; 7) The doctor’s information
2
Student Accessibility Services
☎ 032-626-1198
Tel: 032) 626-1198
Fax: 032) 626-1199
www.sunykorea.ac.kr
(including name, specialty, license/certification number, contact information; 8) Signature of the diagnosing
physician and date. Any additional documentation is welcome and will help in understanding the disability and
classroom needs.
Note: Failure to provide all of the above may result in limited accommodations or rejection of
accommodations request
3
Student Accessibility Services
☎ 032-626-1198
