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University ADA/Section 504 Compliance Officer & Coordinator
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Center for Student Accessibility
521 Lancaster Ave.
Whitlock Building, Room 361, CPO 66
Richmond, KY 40475
Phone: (859) 622-2933
Fax: (859) 622-6794
accessibility@eku.edu

CSA Online Application for Services

Please complete the following application for services.

First Name: *

Preferred Name:

Middle Initial: *

Last Name: *

Pronouns (examples: she/her/hers, he, him, his, they, them theirs): *

Gender Identity: *

Today's Date: *

Date of Birth: *

Are you Hispanic/Latino? : *

Please check all that apply: *

American Indian/Alaskan Native

Asian/Pacific Islander

Black, Non-Hispanic

Caucasian/White, Non-Hispanic

Multi-Racial

Other

Prefer not to say

Are you an international student? : *

Yes

EKU ID#: *

Military Status: *

Have either of your parents completed a 4-year college degree? : *

Are you an online student?: *

Yes

If you take classes in person which campus do you attend? : *

Corbin

Hazard

Lancaster

Manchester

Richmond

Do you commute or live on campus? : *

If you live on campus, what is your campus address? :

EKU E-mail: *

Cell Phone #: *

Permanent Home Phone#: *

Permanent Address: *

City: *

State: *

Zip Code: *

How did you hear about our office? : *

First semester you attended EKU: *

Year in College: *

2 year degree:

4 year degree:

Graduate Degree:

Are you eligible for a Pell Grant?: *

Yes

Not Sure

Did you transfer from another college or University?: *

Major: *

Do you work with Vocational Rehabilitation: *

If yes, what is their name? :

Where did you attend high school? : *

When will/did you graduate from high school? : *

Did you receive academic accommodations in high school? : *

If yes, from where? :

Which of the following accommodations have you used in the past? Check all that apply.: *

Which of the following accommodations have you used in the past? Check all that apply by using the control + alt buttons.

Please mark ALL that apply: I am requesting accommodations because I am an individual with/who has: : *

Please use the control + alt keys to select more than one option.

I am requesting: : *

What housing accommodations are you requesting? : *

Emotional Support Animal

Medical single room

Private bathroom

Room with only one roommate

Semi-private bathroom

Other (specify below)

Housing accommodations are not needed.

Please note that documentation will be reviewed to determine eligibility for accommodations. The process for housing accommodations is separate from academic accommodations, students may be asked to complete additional housing accommodation forms and provide additional documentation.

Assistive Technology:

I use the following assistive technology: Please use the control + alt keys to select more than one option.

If you are Deaf or Hard of Hearing, please answer the following questions. If not, skip to next section.:

Check all services that Vocational Rehabilitation provides:

Are you receiving other forms of financial assistance? :

Which communication system do you use? :

Which assistive listening devices do you use? :

Check the situation that most closely describes your high school::

Will you need assistance evacuating a building during an emergency ? If yes, please reply below.: *

Please mark ALL that apply: I am requesting evacuation assistance because I am an individual with or who is::

Please use the control + alt keys to select more than one option.

All students answer this question:: *

How does your disability create barriers/challenges as a college student in class and/or with housing? From what accommodations would you benefit for an equalizing opportunity?

Leave this field blank:

Inside Look

Fall 2022 CSA Virtual and In Person Tutoring Available

Spring 2022 Tutoring for CSA Students

CSA Syllabus Statement

Eastern Kentucky University strives to make all learning experiences as accessible...

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