Application for Accessibility Services If you need assistance completing this form, please do not hesitate to call: 218.766.2139 BSU Accessibility Services Application Step 1 of 2 50% Which school are you attending?* Bemidji State University Northwest Technical College Date MM slash DD slash YYYY Name* First Middle Last Email* Phone*Do you accept text messages? Yes No Local Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Preferred course delivery method* On-Campus Online Combination Area of Study/Major* Have you applied for services with TRIO?* Yes No What services are you seeking by applying to Accessibility Services?*How does your condition lead to barriers in your classwork?*How does your condition lead to barriers with tests, quizzes and exams?*Describe what strategies or accommodations you’ve had in the past that have worked and how they mitigated the impact of your disability.*Are there any other areas where you find accessing the buildings, courses, materials, events and/or activities challenging?*If you had to categorize your disability, please check all the boxes that apply:* Deaf/Lowered Hearing Blind/Lowered Vision Speech Impairment Motor (body movement) Impairment Mental Health Impairment Attention Deficit Disorder (ADD/ADHD) Specific Learning Disability Chemical Dependency Autism Spectrum Disorder Asperger’s Syndrome Traumatic Brain Injury Systemic Disability Chronic Migraines Seizure disorder Chronic Pain Other If other, please describe* Have you used or do you currently use any assistive technology? Yes No If yes, please list what tools, programs, or apps you have found helpful In High School, were you enrolled with the Special Education Program? Yes No According to the Americans with Disabilities Act, a disability is defined to be a physical or mental impairment that substantially limits a major life activity. Please indicate from the following list, which major life activities are substantially limited by your disability:* Breathing Sleeping Seeing Hearing Caring for yourself Ingesting (Eating/Drinking) Thinking Concentrating Learning Reading Speaking Writing Sitting Reaching Interacting with Others Manipulating (using your hands with efficacy) Standing Walking Bending Lifting Other If other, please describe If you are working with another agency to help support your education, please list them here.Examples include Vocational Rehabilitation, Veteran’s Affairs, Social Services. If you would like Accessibility Services to be able to speak to anyone outside of the BSU/NTC community about your records and information with our office, please list them belowNameRelationshipContact Information To help you from a more holistic perspective, please evaluate yourself in these academic areas.Each area has a rating of strong, good, OK, fair, weak.ReadingStrongGoodOKFairWeakWritingStrongGoodOKFairWeakMathematicsStrongGoodOKFairWeakSpellingStrongGoodOKFairWeakOrganizationStrongGoodOKFairWeakTime ManagementStrongGoodOKFairWeakTaking InitiativeStrongGoodOKFairWeakResponsibilityStrongGoodOKFairWeakStudy SkillsStrongGoodOKFairWeakSelf-AdvocacyStrongGoodOKFairWeakAssertivenessStrongGoodOKFairWeakManagement of Medication (if applicable)StrongGoodOKFairWeakNot ApplicableManaging your DisabilityStrongGoodOKFairWeakNot ApplicableMotivationStrongGoodOKFairWeakNot ApplicableInterpersonal RelationsStrongGoodOKFairWeakNot ApplicableHealthy DietStrongGoodOKFairWeakNot ApplicableRegular ExerciseStrongGoodOKFairWeakNot ApplicableSleep HabitsStrongGoodOKFairWeakNot ApplicablePunctualityStrongGoodOKFairWeakNot ApplicableAdjustment to ChangeStrongGoodOKFairWeakNot ApplicableAccepting CriticismStrongGoodOKFairWeakNot ApplicableCompletion of Tasks on TimeStrongGoodOKFairWeakNot ApplicableFollowing DirectionsStrongGoodOKFairWeakNot ApplicablePlease use the space below to describe any other concerns you may have that have not been addressed above.
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