DSS Self-Identification Form - Disability Services

Name*

First Last

Date*

Student ID Number

Email*

Cell Phone*

Home Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Academic Information

What is your current year level: (choose one)*

First-year (“freshman”)
Sophomore
Junior
Senior
Graduate Student
Continuing Education (CE)
Dual Enrollment (High School)
Other/I don’t know

For which semester are you requesting accommodations: (choose one)*

Fall
Spring
Summer

For what year: (type year)*

Please select your school (choose one):*

College of Arts and Sciences
Continuing Education for Educators
School of Professional Studies
Nursing & Health Professions
School of Education
Trinity at THEARC
Business and Graduate Studies

What is your major?*

Are you living on-campus or will you commute to campus? (choose one):*

On-campus
Commute

Disability Information: (check all that apply)*

If you indicated “Other/Temporary” as the type of disability you have, please provide additional information.*

Please describe your disability and how it impacts you in an academic setting:*

Have you ever received accommodations before:*

Yes
No

If yes, what accommodations have you received in the past:*

Please list any accommodations you are currently requesting at Trinity Washington. Please note this does not guarantee the requested accommodation will be assigned:*

Is there any additional information you would like to share?

Upon receipt of this form, the staff of DSS will contact you to schedule an appointment regarding registration procedures, submission of documentation, etc. Submission of this form is kept as CONFIDENTIAL.