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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: *

Have you received accommodations from CSA before? If yes, when? : *

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.

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

CSA Syllabus Statement

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

Accessibility Gains Must Become Lasting Learning Practices

Inside Higher Education: ...

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