Disability Services, Intake Form

Volunteer State Community College | Student Services Division

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Office Information:
Office Hours: 8:00-4:30, Monday-Friday
Office Location: 122 Randy & Lois Wood Campus Center
Office Phone Number: (615) 230-3472, TDD: (615) 230-3488
Office Fax Number: (615) 230-4808

If you would like to contact our office via email please complete the following online form.

Please fill in and click the Submit button.

* Represents fields that must be entered to submit this form.
* First Name:
* Last Name:
Address:
City:
State:
Zip Code:
Country:
Work Phone:
* Home Phone:
Fax:
E-Mail Address:
Student Identification Data:
Date of Birth:
Sex:	*Please Select Male Female
Please Select All That Apply:
Please describe your disability (i.e. learning, hearing impaired, etc.)	Learning Disability ADD/ADHD Psychologically Impaired Visually Impaired Hearing Impaired Chronic Health Other
List current medications:
Are you a Vocational Rehabilitation client?	No Yes
If yes, please provide the name and number of your counselor:
Do you receive financial aid?	No Yes
Are you a Veteran?	No Yes
Would you like to register to vote?	No Yes
Responsibility: It is the student's responsibility to voluntarily and confidentially disclose information regarding the nature and extent of the qualifying disability. The college does not assume responsibility for providing accommodations or services to students who have not identified themselves as having a qualifying disability.
I Disagree I Agree
Disclosure: I do herby give permission for the Disabilities Services Office to act as an advocate on my behalf with my instructors, vocational rehabilitation counselor, and other significant VSCC staff members. I understand that it is my responsibility to meet with each of my instructors to discuss and request accommodations.
I Disagree I Agree
Parental and Significant Other Consent: (if applicable) I give my permission for the staff in the Disability Services Office to speak with my parents or significant other concerning my activities at VSCC.Â
No Yes
Please hold down your Control Key (Apple Key for Macintosh Users) to select multiple choices.
Please list the accommodations you will need at VSCC:	Extra Time on Test Oral Testing Test Proctoring Non-Distractible Environment Allow breaks such as standing Allow Food and Drink Special Chair/Desk/Seating Mentoring/Counseling Allow Makeup Work on Assignments
Please list some of the auxiliary aids you will need at VSCC:	Tape Recorder Notetaker Instructor's Notes (if available) Reader Books on Tape/CD Interpreter/Sign Language FM Listening Device Vocal Repeater Braille Printed Material Enlarged Text Material Calculator/Spell Checker Adaptive Computer Training Tutoring
Please list any accommodations and auxiliary aids you have used before:	Extra Time on Tests Oral Testing Test Proctoring Non-Distractible Environment Allow breaks such as standing Allow Food and Drink Special Chair/Desk/Seating Mentoring/Counseling Allow Makeup Work on Assignments Tape Recorder Notetaker Instructor's Notes Reader Books on Tape/CD Interpreter/Sign Language FM Listening Device Vocal Repeater Braille Printed Material Enlarged Text Material Calculator/Spell Checker Adaptive Computer Training Tutoring
In your own words, please describe how your disability impacts your daily life and education:
How do you cope with limitations of your disability?
Please share any other information that you feel would be helpful to Disability Services:
After this form is submitted you will be contacted by the staff of Disability Services.  If you have any questions please contact the Office of Disability Services at:  (615) 230-3472 or TTD (615 )230-3488