HTML Preview Student Intake Form page number 1.
STUDENT INTAKE FORM
_______________________________________ ___
Date Completed: _______________________________
Name: ____________________________________________ Academic Year: ________________
Address:_________________________________________________________________________
Phone: ________________________________ID#: ______________________________________
Email Address: __________________________________________________________________
Disability: (Check all that apply)
_____ Attention Deficit/Hyperactivity Disorder _____ Learning Disability
_____ Psychological/Psychiatric Disorder _____ Blindness/Low Vision
_____ Medical/Physical Disability _____ Deaf/Hard of Hearing
_____ Spinal Cord/Traumatic Brain Injury _____ Speech Disorders
_____ Other (please specify):
______________________________________________________
Accommodations you would like: (Check all that apply)
____ Extended test time ____ Test in private
____ Note taking ____ Sign language interpreter
____ Priority seating ____ Use of laptop / word processor
____ Use of Calculator ____ Waiver of absence policy (health reasons)
____ Print enlargement ____ Tape record
____ Test reader/writer ____ Other (please specify):
______________________________________________________
*Please note: Documentation is very important tool to help us give you the most appropriate
accommodations and the documentation you submit should include diagnosis and
information to justify each accommodation you are requesting.
Are you interested in receiving tutoring services at BridgeValley? Yes ______ No ______
(If yes, your name and contact information may be shared with our Tutoring Services Office.)
DESCRIBE THE DIFFICULTIES YOU EXPERIENCE RELATED TO YOUR DISABILITY (i.e.,
reading, writing, concentration, memory, time management, etc.):
PLEASE INDICATE ANY TREATMENT YOU ARE RECEIVING INCLUDING MEDICATIONS:
(include medication dosages if known)