SAC Registration Form

* indicates a required field

Student Information

The purpose of this form is to give you, the student, an opportunity to tell the Student Access Center (SAC) how your environment may be impacted by your accessibility needs and what reasonable accommodation you are requesting. Information provided on this form is confidential. The registration process must include the following steps:

1. Complete this Registration Form & upload SAC's Academic Accommodation Policies & Procedures

2. Upload current and comprehensive medical documentation (prepared by an appropriate licensed professional, such as a medical doctor, psychologist, psychiatrist or other qualified diagnostician)

3. Upload a Student Access Center Verification Form (Completed by referring healthcare specialist)

4. Schedule an intake appointment with an Access Specialist

First Name

Last Name

Middle Name

Preferred Name:

Pronouns:

Other

DOB

Student ID

900#

Spelman Email

Please use your Spelman email address

Alternate Email

Preferred Contact #:

Alternate #:

Local Address or Residence Hall Assignment:

Permanent Address

Referred by:

Student Status

Classification:

Accommodation History

List accommodations and/or services provided in high school and previous higher education community

Disability/Accommodation Information

Do you have a diagnosed disability?

Diagnosed Categories (check all that apply)

Diagnosis Subcategories (check all that apply)

*Note: If your medical condition is not permanent in nature, the College is not required by law to provide any accommodation, but after review, SAC may be able to assist you on a temporary basis.

Year of initial diagnosis:

Year of most recent evaluation:

Requested Accommodation(s)

Upload supporting document(s)

See Verification Form in determining the appropriate licensed professional to provide current and comprehensive documentation

Granting Permission for SAC to Release Information to Spelman Faculty & Staff

Signature

I certify that the information provided on this form is accurate. I understand that to be eligible for disability services at Spelman College I must (1) submit this completed form, (2) meet with Student Access Center for an intake interview, (3) review recommended accommodation(s) (4) review documentation guidelines, and (5) submit current and comprehensive disability documentation. Documentation of your disability is required in order to determine your eligibility for accommodations. Please have your medical professional send the Student Access Center documentation of your diagnosis clearly outlining the functional limitation that would keep you from having an equal opportunity while pursuing your educational program. The Family Educational Rights and Privacy Act (FERPA) (20 U.S.C. § 1232g; 34 CFR Part 99) is a federal law that protects the privacy of student education records. In accordance with FERPA, Spelman College may not disclose certain education records or information contained there without written permission from the student. My signature authorizes SAC to discuss my documentation with the clinician who authored the documentation or a similarly qualified Spelman staff person or consultant if additional information or clarification is required

SAC Registration Form

Student Information

Accommodation History

Disability/Accommodation Information

Document Information