STUDENT ACCESSIBILITY CENTER
STUDENT INTAKE FORM
  1. Date:                   
  2. Name:                                                                                                    
    3.           first                  MI                    last
  3. Student ID #    9         9                                                                
  4. Male              Female         
  5.  Date of Birth         /        /      
  6. Ethnicity (optional)
1. African American        
2. Asian         3. Native American        
4. Hispanic/Latino        
5. Caucasian         6. Other        
  1. Preferred Mailing Address
                                                                                                                                                                      
     Street                                                 City               State                Zip
  1. Preferred Telephone #                                               Circle one if applies-  TTY / VP  IP#                                
  2. UWM Email Address                                                Preferred Email for SAC use, if different                         
    3. Note: The University will use your UWM email address for all official contact, including class email lists. You can set your UWM email to forward all mail to another address.

  3. First Semester at UWM: (circle one)   Spring   Fall    Summer     Winterim   Year:                  

  4. Have you used the Student Accessibility Center in the past? Yes        No         If Yes, when?                
  5. Major                                                          Academic Advisor                                                
  6. Are you receiving funding from the Division of Vocational Rehabilitation (DVR)? (circle one)     Yes   No
  7. If Yes, counselor's name and phone number                                                                 
  8. Are you a Veteran?  Yes          No          Are you receiving Military Education Benefits?    Yes           No        
  9. Previous colleges/universities attended:
    10.                                                                                                                                                                             

    Please turn to back and check all documented disabilities that you think might affect your education and can be helped by accommodations.

    Indicate P (Primary) and S (Secondary) if more than one disability.

  10. Is your disability:  Permanent          Temporary            If temporary, how long do you expect it to last?                

    11. Mobility/Physical
    		 Health
    		 Sensory/Communication
          Paraplegia
    		       AIDS/HIV Positive
    		       Deaf
           Quadriplegia
    		       Alcohol/Chemical Dependency
    		        Hard of Hearing
          Cerebral Palsy
    		       Asthma/Respiratory Disease
    		        Speech Impairment
          Amputation
    		       Cardiac Condition
    		       Visual Impairment
           Arthritis/Rheumatism
    		       Chronic Pain
    		 Other
           Multiple Sclerosis
    		        Cystic Fibrosis
    		       Learning Disability
          Muscular Dystrophy
    		       Diabetes
    		       ADD/ADHD
          Spina Bifida
    		       Seizure Disorders
    		       Autism Spectrum Disorders
          Recurrent Dislocations
    		        Hemophilia
    		       Brain Injury
          Lupus
    		       Kidney Disease
    		       Psychological Disability
          Lyme's Disease
    		       Cancer
    		       Diagnosis in Progress

    		      Fibromyalgia
    		       Other (specify below)

    		      Crohn's Disease
    		                                         

    		      Sickle Cell Anemia


  11. Please describe the nature of your disability more completely                                                                           
    12.  
  12. What accommodation services have you received in the past?                                                                         

  13. What accommodation services are you interested in receiving?                                                                           

  14. Student Signature                                                                               

    15. Provision of disability-related services may involve SAC communicating with appropriate university personnel who have a legitimate educational interest.

    Intake Counselor                             Checked for accuracy/completeness?            Disabilities labeled P & S?           

    Data Entry Date                                

    last revised 5/14/07