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Disability Services

New Student Information Form

Personal Information











Other Colleges Attended:
1. 2. 3.



If you answered YES to this question, please provide us with the name, business address, and phone number of your DARS counselor:




Check all Disabilities The following CONFIDENTIAL questions are for State/Federal statistical reporting only.

Asperger's Syndrome
Attention Deficit Disorder
Autistic Disorder
Learning Disability
Substance Abuse - Alcohol/Drug
Mental or Emotional Disorder
Low Academic Skills
Arthritis (Severe)
Asthma
Back Injury 		Visual Impairment
Burn
Cancer
Cerebral Palsy
Circulatory Problems
Deafness - 40 DB or more
Diabetes Mellitus - on Insulin
Epilepsy
Hearing Impairment
Brain Injury
Heart Condition 		Hypertension
Loss of Limb
Mobility Impairment
Multiple Sclerosis
Muscular Dystrophy
Other Disabilities
Sickle Cell Anemia
Speech Impairment
Spinal Cord Injury
Stroke
Copyright © 2009 Richland College | DCCCD | Last Updated: Thursday, January 8, 2009