If you have a physical, psychological, or cognitive disability and would like to identify yourself to the Disability Support Services (DSS) office, please complete this form and return it back to DSS. By doing so, you are indicating that you would like to learn more about support services that may be beneficial to you while attending Trinity Washington University. The information that you provide on this form is for the purpose of facilitating contact between you and Disability Support Services (DSS). DSS staff can then explain the process of registering for support services such as classroom accommodations. It does not impact admissions/enrollment decisions. Name* First Last Date MM slash DD slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneEmail* Date of last Psycho-Educational Assessment MM slash DD slash YYYY When do you plan to enroll at Trinity?* Fall Spring Summer Year you plan to enroll* Please select your school* 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 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.