Disability Support Resources

First Name:*

Middle Initial:

Last Name:*

Date Of Birth:*
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

G Number:*
(ex. GXXXXXXXX)

Gender:*
Male Female

Ethnicity:
Asian American/Asian
American India/Alaskan Native
African American/African
Caucasian
Hispanic
Multinational

Which best represents you:*
Faculty Staff Student

Local/Campus Address:*

Address City

State - Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Zipcode

Phone Number:*
(xxx-xxx-xxxx)

E-mail Address:*

Disability Conditions:* (please check all that apply)

ADHD Physical Disability
Chronic Illness Mobility Impairment
Hearing Impaired/Deaf Psychological Disability
Learning Disability Traumatic Brain Injury
Visual Impairment/Blind Other Please specify:

Are you on any prescribed medication related to your disability at present?*
Yes No Please specify:

Are you associated with any rehabilitation service? (i.e. MI Rehab/MI Commission for the Blind)*
Yes No Please specify:

How did you learn about the DSR? (please check all that apply)

DSR Website Union Representative
Ombudsperson Supervisor/Unit Administrator
Human Resources Office of Inclusion and Equity
Other Please specify:

Are you currently enrolled at GVSU?*
Yes No When do you intend to enroll? Fall Winter Summer

Year 2013 2014 2015 2016 2017 2018

Class Standing:*
Freshman Sophomore Junior Senior Graduate

Are you an International Student?*
Yes No

Will you be receiving financial aid? (grants, loans, and/or scholarships)*
Yes No

Intended Major(s):*

Career Goal:

College(s) Previously Attended:

Are you employed?*
Yes No How many hours per week?:

What type of accommodations do you use to assist you at your university or home?

Are you requesting Housing accommodations?*
Yes No

Semester requesting accommodations to begin:
Fall Winter Spring Summer 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

Classification:
- Incoming Freshman Incoming Transfer Current Student Graduate Student

I am requesting:
Wheelchair Accessible Room
1-Bedroom (Single) Apartment
Single Bedroom in a 2 or 4-Bedroom Apartment
Reduced Access to a Bathroom
Un-lofted bed (Tower building)
1st Floor Assignment
Other
Please Specify:

How do you anticipate managing your symptoms in other campus settings (e.g. classrooms, dining halls, libraries, etc.)?

Explain how the accommodations you are requesting will help you manage your current symptoms.

City: *

Country: *

School transferred from: *

What types of services do you use through your University or school at home?

What everyday items do yo use to assist your disability at home that you will NOT bring to GVSU?

Is there anything else that you would like to add that could help GVSU in assisting you?

Please state your employment affiliation: (i.e. faculty, librarian)*

Job Title:*

Employee ID:*

Department Name:*

Name of Supervisor/Unit Administrator:*

Permanent Number:* (xxx-xxx-xxxx)

Campus Telephone:* (xxx-xxx-xxxx)