Please mark the appropriate responses. If the answer to question "1" is "No", do not complete or return this form.
| 1. Do you have a disability that substantially limits one or more major life activity, such as those listed in number 3? ___ Yes ___ No | |||
| 2. What is the nature of your disability? | |||
| ___ AD/HD | ___ Blind | ___ Deaf | ___ Hearing impaired |
| ___ Learning disabled | ___ Mobility impaired | ___ Visually impaired | ___ Other (please list) _____________ |
| 3. Limited major life activity: (check all that apply) | |||
| ___ Hearing | ___ Learning | ___ Physical activity | ___ Reading |
| ___ Seeing | ___ Speaking | ___ Walking | ___ Other (please list) _____________ |
4. Will you receive assistance from Vocational Rehabilitation, the Division of
Services for the Blind, or other agencies?
___Unsure
___ No
___ Yes
If "yes", provide the name of your counselor/contact____________________________
Personal Information
Name _______________________________ CWID/Soc. Sec. Number ___________________
Address ____________________________________________________________
City ___________________________ ZIP ______________ Phone ___________________
Academic major: _________________________ New Student? ___Yes ___No
Date of Birth _______________ Year High School diploma/GED received __________
*Registered to vote? ____Yes ____No
You may register to vote in the Services for Students With Disabilities office.
I certify that this information is accurate and may be used by college personnel to provide assistance or services to me. I agree to furnish any documentation that may be required. I understand that any costs for obtaining documentation are my responsibility.
Student signature ______________________________ Date ________________
Return this completed form to Services for Students With Disabilities,
PSTCC, 10915 Hardin Valley Rd.,P.O. Box 22990, Knoxville, TN 37933-0990
Fax: (865) 539-7218; Phone: (865) 694-6751