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Student Registration Form

* indicates a required field

Student Information

Please enter your information

First Name(Required) *

Last Name(Required) *

Middle Name

Student ID(Required) *

Email(Required) *

Please use your college issued email address

Phone Number(Required) *

Specific Accommodation Information

My diagnosed disabilities fall into the following categories(Required) *

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) *

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

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) *

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

Are you requesting an academic accommodation?(Required) *

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

How does your disability affect you academically?(Required) *

How does your disability affect student life in general?(Required) *

Did you receive accommodations in high school? (Required) *

(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) *

Are you requesting a housing accommodation?(Required) *

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

I request the following accommodations for housing(Required) *

[Select]

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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) *

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

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