Banacos Academic Center

Disability Services

413-572-5789

ds@westfield.ma.edu

Registration Form

Name: UWID#:

Address: Phone: (i.e. 555-555-5555) Cell Provider: (i.e Verizon, AT&T, etc.)

WSU Email: @westfield.ma.edu Date of Birth:

Major 1: Major 2:

Previous School (college or high school):

Status: Day Student	CGCE Undergrad Student Graduate Student

Are you involved in or use services from any of the following? Check all that apply.

TRIO

Urban Education

Veteran Services: on campus	VA

Student Athlete - Athletic Team(s):

State Vocational Rehabilitation - Agency:

Counselor name:

Phone: Email:

Other:

Do you work?

No	Yes How many hours per week?

What is your disability? Check all that apply.

Learning Disability

Deaf/Hard of Hearing

Blind/Low Vision

ADD/ADHD

Autism Spectrum

Mobility Related

Mental Health related

Brain Injury:

Date of last injury:

Chronic Illness:

Chronic Pain:

Other:

How do you think your disability will affect you at Westfield State?

What accommodations and services have you used in the past?

Exam Accommodations

50% (time and a half) extended time

100% (double time) extended time

Reduced distraction environment

Reader

Scribe

Flexible Attendance (describe):

Sign Language Interpreter

CART

FM System

Voice Recorder

Note taker

Alternative Format Textbooks (describe):

Other:

Do you need assistance during an emergency evacuation?

No

Yes (describe):

Signature: Date:

**If submitting this form electronically, it must come from your Westfield State email address.**

Please note: This form is for beginning the registration process only. Students who want to request reasonable accommodations must meet with the Disability Services staff, 413-572-5789, ds@westfield.ma.edu AND submit a Reasonable Accommodations Request Form.