Student Intake Form

Name*

College Wide ID Number*

Mailing Address*

City*

State*

ZIP Code*

Phone*

Primary Disability*

Secondary Disability

Select Campus*

Are you a client of Louisiana Rehabilitation Services?

Yes

No

What is your rehabilitation counselor's name?

What is your rehabilitation counselor's phone number?

The accommodations and services will not be provided until you have turned in approved disability documentation. Send documentation to disabilityservices@dcc.edu. The documentation guidelines will be provided to the students with disabilities.

If the need arise, would you allow the disability services coordinator to discuss your academic performance with instructors, administrative staff, and/or rehabilitation counselors?

Yes

No

I understand that all information will be kept confidential unless I have specified its release. The name listed below will serve as my digital signature.

Your Name*

Date

City Park Campus
West Bank Campus
Charity School of Nursing
Jefferson Site
Sidney Collier Site

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Student Intake Form