Registration Form

Name:

Date:

DOB: (mm/dd/yyyy)

Campus Email:

(full email required)

Permanent Address

Local Address

Street:

City:

State:

Zip:

Phone Numbers

Permanent:

Cell:

Did you receive Vocational Rehabilitation services? Yes or No

** If yes, who is your case manager?

_________________________________________________________________________________________________________

Student Status:

Prospective:

(Date of Anticipated Enrollment)

Enrolled in Continuing Education Courses:

Name of Course(s)

Transient:

Name of Institution You Attended on a Regular Basis

Undergraduate:

Date of Enrollment at LU

Degree(s) Seeking

Anticipated Graduation:

GPA:

Credits: (Completed)

__________________________________________________________________________________________________________

Diagnostic Information:

Please state your diagnosed disability(ies) and the date of onset:

Please describe how your affects you both outside and inside the classroom, including testing and studying situations:

Name and contact information of the Medical Professional(s) treating the impairment(s) stated above:

__________________________________________________________________________________________________________

Functional Limitations: Please check any of the major life activities listed below you believe are affected as a result of your diagnosed condition. Please indicate level of limitation you believe you experience as a result of the condition.

__________________________________________________________________________________________________________

Service History: Please check/describe any services you have received in the past under "Previously Received". Please check those services you are interested in requesting at Longwood University under "Requesting at LU".