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* 1. First Name

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* 2. Last Name

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* 3. E-Mail Address

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* 4. Phone Number

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* 5. Date of Birth (Month/Date/Year)

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* 6. Please select your major

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* 7. How will you be completing your coursework?

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* 8. Your diagnosed disability falls into the following category?

(There is much variability within each accessibility category, and therefore, the type of accommodations needed can vary significantly.  Here you will find descriptions of the various types of disabilities recognized in the United States)

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* 9. How does your disability affect you academically?

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* 10. How does your disability affect student life in general, like getting around campus and attending class?

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* 11. Have you previously used accommodations at school or work?

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* 12. What accommodation have you used previously?

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* 13. What accommodations are you requesting to use at Valor Christian College?

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* 14. Please provide any additional information that can assist in organizing your accommodations.

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