ࡱ> DFCK bjbj:S:S 2X94iX94i*****>>>>Z<>8ccc$f*cA"ccc**???c **?c???5tm ?08? wj ? *?dcc?ccccc^ccc8cccc cccccccccX :  Eastern Illinois University Accessibility & Accommodations Initial Intake Form E Number: ________________________ Optional: Ethnicity: ___________________ Name: ___________________________ Optional: Birth Date: __________________ Campus Address: _______________________________________________________________ Cell Phone: _______________________ Campus Email: ___ HYPERLINK "mailto:____________________@eiu.edu" ____________________@eiu.edu Optional: Parent(s) Name _________________________________________________________ Permanent Home Address: _______________________________________________________ City, State and County: ___________________________________________________________ US Veteran? Yes or NoBranch? Army Marines Navy Air Force Coast Guard Guard Reserves Transfer Student? Yes or NoFrom?Gateway Program? Yes or NoClass Level: FR SO JR SR GraduateFirst Generation College Student? Yes or NoAdvisor Name:Major:Minor: What is the disability for which you are requesting accommodations? _____________________ ____________________________________________________________________________________________________________________________________________________________ How old were you when you were diagnosed with the disability? _________________________ Do you have a Department of Rehabilitation (DRS) sponsorship? Yes No Applied Not Eligible Please list accommodations used at high school and/or previous institutions: _______________ ______________________________________________________________________________ What accommodations are you requesting? _________________________________________ ____________________________________________________________________________________________________________________________________________________________ I understand that specific information is required for documentation of different types of disabilities and that accommodations will be considered only after the disability has been verified according to A&A Documentation Requirements. 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