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STUDENT INTAKE FORM Date Completed: Name: Academic Year: Address: Phone: ID : Email Address: Disability: (Check all that apply) Attention Deficit/Hyperactivity Disorder Learning Disability Psychological/Psychiatric Disorder Blindness/Low Vision Medical/Physical Disability Deaf/Hard of Hearing Spinal Cord/Traumatic Brain Injury Speech Disorders Other (please specify): Accommodations you would like: (Check all that apply) Extended test time Test in private Note taking Sign language interpreter Priority seating Use of laptop / word processor Use of Calculator Waiver of absence policy (health reasons) Print enlargement Tape record Test reader/writer Other (please specify): Please note: Documentation is very important tool to help us give you the most appropriate accommodations and the documentation you submit should include diagnosis and information to justify each accommodation you are requesting..
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