Student Accessibility Center

Prospective Student Form

Today Date:

Is this your first contact with the Student Accessibility Center?:

Yes

Last contact with SAC:

Last Name:

First Name:

Middle Initial:

Phone:

Student ID:

E-mail:

Primary Disability:

Secondary Disability:

How does your disability affect your ability to attend class and learn?

Disability Effect:

Mailing Address:

City, State:

ZipCode:

Best way to contact me:

phone

E-mail

first semester at UWM :

Please pick up the appropriate brochure.
LD/ADHD - Ann and Barb
Autism Spectrum Disorders - Barb
Brain injury - Ann
Visual Impairment - Jean
Psychological - Jon
Mobility/Physical - Jean
Deaf/Hard of Hearing - Laurie

TO BE COMPLETED BY SAC (when student does not complete form)

Staff Initials:

Type of Contact:

phone/TTY

letter

office visit

e-mail

Contacting Individual:

student

school

relative

other

Contact Individual (if other):

Contact Name and Phone Number:

Staff or Counselor Comments: