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Student Registration Form
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Student Information
Please enter your information
First Name
(Required)
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Last Name
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Middle Name
Student ID
(Required)
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Email
(Required)
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Please use your college issued email address
Phone Number
(Required)
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Specific Accommodation Information
My diagnosed disabilities fall into the following categories
(Required)
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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?
(Required)
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Have you been tested and/or received a diagnosis in the past three years?
(Required)
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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?
(Required)
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Are you requesting a medical accommodation?
Yes
Are you requesting a medical accommodation?
no
Are you requesting an academic accommodation?
(Required)
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Are you requesting an academic accommodation?
Yes
Are you requesting an academic accommodation?
no
How does your disability affect you academically?
(Required)
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How does your disability affect student life in general?
(Required)
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Did you receive accommodations in high school?
(Required)
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(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?
(Required)
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Are you requesting a housing accommodation?
(Required)
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Are you requesting a housing accommodation?
Yes
Are you requesting a housing accommodation?
no
I request the following accommodations for housing
(Required)
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[Select]
[Select]
Single Room
Air Conditioning
Emotional Support Animal
Room near restroom
Room with private bath
Gender Neutral Housing
Exemption from Campus Housing
Other (Please explain below)
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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)?
(Required)
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Please state how your housing accommodation request will assist with or ameliorate symptoms of your stated disability.
(Required)
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