CSA Online Application For Services

First Name: *

Middle Initial: *

Last Name: *

Today's Date: *

Date of Birth: *

EKU ID#: *

Campus Address:

E-mail: *

Cell Phone #: *

Permanent Home Phone#: *

Permanent Address: *

City: *

State: *

Zip Code: *

How did you hear about our office? :

Year in College: *

2 year degree:

4 year degree:

Graduate Degree:

Major: *

Do you work with Vocational Rehabilitation: *

If yes, what is their name? :

Where did you attend high school? : *

Did you receive academic accommodations in high school? : *

Did you transfer from another college or University?: *

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: : *

Assistive Technology:

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

Are you receiving other forms of financial assistance? :

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.

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

Which communication system do you use? :

Which assistive listening devices do you use? :

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?

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