Registration Form

Questions

1. Do you have a non-Evergreen email address that we can contact you at if needed? (Note: We will always use your Evergreen emal address as the primary.)
2. Please describe your disability (or temporary medical condition) and how it may impact you as a student at Evergreen.
3.  

   Have you used accomodations in your previous school experience? * (Selection is Required)

   Yes (Specify Below)

   No

   Additional Note or Comment
4. What classroom or academic accommodations would you like to request at Evergreen?
5.  

   Are you requesting accommodations for any of the following (check all that apply):

   Study Abroad

   Field Work / Trips

   Internships

   Not at this time.

   Additional Note or Comment (Specify Below)

   Additional Note or Comment
6.  

   Are you receiving services through any of the following:

   Department of of Services for the Blind (DSB)

   Department of Social and Health Services (DSHS)

   Division of Vocational Rehabilitation (DVR)

   Veterans Affairs (VA)

   None

   Other (Specify Below)

   Additional Note or Comment
7.  

   How did you learn about Access Services? (check all that)

   Evergreen faculty

   Evergreen academic advisor or admissions counselor

   Evergreen student

   High school counselor or teacher

   Received services at another college or university

   Access Services website

   Access Services staff member presentation

   Other (Specify Below)

   Additional Note or Comment