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Student Registration Form

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Student Information

Please enter your information

First NameRequired *

Last NameRequired *

Middle Name

Student IDRequired *

EmailRequired *

Please use your college issued email address

Phone NumberRequired *

Are you requesting a COVID19 Remote Online Learning Adjustment?

Are you requesting a COVID19 Remote Online Learning Adjustment? Yes Are you requesting a COVID19 Remote Online Learning Adjustment? no

Explain circumstances that will make face-to-face learning challenging during the current COVID 19 situation. Required *

Please upload documentation that support your circumstances explained above. Documentation should come from a professional medical or mental health provider.

Specific Accommodation Information

My diagnosed disabilities fall into the following categories

If you selected Chronic Health above, please specify

If you selected Temporary Injury & Health Conditions above, please specify

These conditions could include temporary orthopedic conditions, concussions and temporary medical conditions. Temporary is lasting for only a limited period of time.

If you selected Other above, please specify

How and when was your disability diagnosed and documented?

Have you been tested and/or received a diagnosis in the past three years?

Have you been tested and/or received a diagnosis in the past three years? Yes Have you been tested and/or received a diagnosis in the past three years? no

Are you requesting a medical accommodation?

Are you requesting a medical accommodation? Yes Are you requesting a medical accommodation? no

Are you requesting an academic accommodation?

Are you requesting an academic accommodation? Yes Are you requesting an academic accommodation? no

How does your disability affect you academically?

How does your disability affect student life in general?

Did you receive accommodations in high school?

(ex: IEP, 504, etc.)

Did you receive accommodations in high school? Yes Did you receive accommodations in high school? no

What type of accommodations have you used?

Are you requesting a housing accommodation?

Are you requesting a housing accommodation? Yes Are you requesting a housing accommodation? no

I request the following accommodations for housing

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Other Housing Accommodation

Please Explain

How does your disability affect your ability to enjoy standard Hanover College housing (double room without AC)?

Please state how your housing accommodation request will assist with or ameliorate symptoms of your stated disability.

Upload supporting document(s)

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