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Student Forms
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BSC Student Accessibility Application
Please complete this form for the SA office to have on file. If you have any questions, please call 701-224-2496.
Personal Information
* First Name:
this field is required
* Middle Name:
this field is required
* Last Name:
this field is required
* Current Address - Street:
this field is required
Current Address - PO Box
* Current Address - City:
this field is required
* Current Address - State:
this field is required
* Current Address - Zip Code:
this field is required
* BSC Email Address:
this field is required
* Student ID Number:
this field is required
* Cell Phone Number:
this field is required
* Term you are applying for:
this field is required
select one...
Fall
Spring
Summer
* Seeking a degree in:
this field is required
Disabilities and Accommodations
:
* Please list any disabilities that have an impact on your academic work (Physical, Learning, etc.).
It is necessary to supply current documentation from an appropriate professional to support each area of disability:
this field is required
* Who is the most recent provider to diagnose or treat symptoms related to the disability?:
this field is required
* Please explain how you are affected by the disabilities indicated above:
this field is required
* Please check the area(s) below impacted by those disabilities:
You need to check this item to proceed.
Reading
Writing
Speaking
Attention
Hyperactivity
Anxiety
Mathematics
Language Study
Note-taking
Visual Processing
Auditory Processing
Other
* Please discuss academic accommodations or special considerations you have had in your previous education (i.e., at your high school or at another college or university):
this field is required
* Did you have an IEP or 504 plan in high school?
this field is required
Yes
No
* Have you received accommodations at a previous college?
this field is required
Yes
No
If yes, please list the name of the college or university.
* Please describe the accommodations you are requesting to receive at BSC:
You need to check this item to proceed.
Access to Food, Drink, or Medication During Class
Captioning
Distraction Reduced Testing Area
eBooks
Enlarged Font
E-Text
Extended Testing Time
Help with Note-taking
Peer Mentoring
Preferential Seating
Severe Allergy
Sign Language Interpreter
Test Reader
Other
If other, please type details:
What other information would be helpful to the BSC staff to know about you?:
* What are your strengths as a student?
this field is required
How were you referred to the Student Accessibility Office:
*
By checking the box, I agree to allow the Student Accessibility Coordinator, or designee, to determine whether pertinent staff members should be informed of my disability information in order to fully support my needs.
You need to check this item to proceed.
I agree