Intake Form

  •   Male
      Female
  •   African American
      Asian/Pacific Islander
      Hispanic/Latino
      Native American
      White
      Other
  •   Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder (ADD or ADHD)
      Autism Spectrum Disorder including Asperger Syndrome
      Cognitive including Intellectual Disability or Mental Retardation
      Courtesy Services (e.g. pregnancy / over-size seating etc.)
      Depression/Anxiety or Mental Illness/Psychological or Psychiatric Condition including Post-Traumatic Stress Disorder (PTSD)
      Hearing
      Health Impairment/Condition
      including Chronic Conditions
      Learning Disability
      Mobility Limitation/Orthopedic Impairment
      Speech/Language
      Traumatic Brain Injury
      Veteran with Service Condition
      Vision
      Other

  •   Permanent or not expected to change during the semester
      Temporary
      Long term but condition changing
      Duration unknown

  • Please answer the following information for institutional purposes however, this information is optional.
  •   Yes
      No

  •   Yes
      No
  •   Yes
      No
  •   Yes
      No
  • If you wish to request accommodations at CASC, it may be necessary for the ADA Coordinator to forward this request to CASC staff, instructors and/or Physical Plant. When accommodations are needed in the classroom, the ADA Coordinator will notify the instructor. This notification is done only with the permission of the student and/or guardian. Please read the statement below and sign if you agree with the statement.

    I understand that it may be advisable for the ADA Coordinator to notify the staff/instructors of the disability and need for special accommodations. Therefore, I give permission to the ADA Coordinator to provide the information identified on this sheet to the staff/instructors.

    In order to receive ADA service, I understand that I must complete the Request for Special Accommodations Form with documentation of my disability. I am also aware that I must visit the ADA Coordinator Crissy Keaton located in the Learning Resource Center on the third floor of the Ollie Center.
    each semester in order to continue this service.

  • By signing below I am stating that the Carl Albert State College Disability Services Office has notified me of my rights to register as an Oklahoma voter and has also given me an Oklahoma Voter Registration Application if I have not yet registered. The Carl Albert State College Student Disability Services Office has also given me the option of filling out the Oklahoma Voter Registration Application in the student disability office with the promise that they will mail the application for me.





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