Accessibility Services – Intake Form

About You

Name(Required)

First Last

Preferred Name

Pronouns

Niagara College Student ID Number

Provide your 7 digit Niagara College student ID number, if known.

Contact Information

Email(Required)

Enter Email Confirm Email

Home Phone

Mobile Phone

Academic Profile

What type of student are you?(Required)

Niagara College Program(Required)

What is the difference between a Part-Time student and Part-Time Studies student? A part-time student is registered in a full-time program but without a full-time course load. A Part-Time Studies student is when a student is registered as “part-time” through the Part-Time Studies department.

Are you an apprenticeship student?(Required)

Yes

Are you an international student?(Required)

Yes

Do you self-identify as an Indigenous student (First Nations, Métis, Inuit, or Non-status)?(Required)

Yes

Funding and Sponsorship

Are you receiving any funding?

Please select all that apply.

OSAP

OSB

Service Canada

WSIB

Better Jobs Ontario

First Nations Band

Other

What other funding are you receiving?(Required)

Are you receiving any sponsorship?

Please select all that apply.

March of Dimes

Canadian Mental Health

CNIB

CHS

Other

What other sponsorship are you receiving?(Required)

Support Profile

You are not required to disclose your disability or condition to register for accessibility services and access accommodations and supports.

Have you been diagnosed with a disability, health or mental health condition?(Required)

Supporting Documentation

You will be asked to provide any documentation that supports your diagnosis (ex. Psychoeducational Assessment, OSAP Disability Verification Form, Functional Limitations Form, medical documentation, etc.) to your Accessibility Consultant. Please be prepared to provide this docuemntation ahead of your intake appointment.

Are you in the process of being assessed for a disability, health or mental health condition?(Required)

Are you taking any medications that may impact your academic performance?(Required)

Medication Side Effects(Required)

Please list any medication side effects that you experience.

Have you had an accommodation letter (ex. LOA, IEP) before?(Required)

What accommodations have you used to assist you?(Required)

Assistive technology (ex. Read Write, Dragon, etc.)

Alternative formats (ex. large print, audiobooks)

Extensions on projects

Extra time for tests

FM system

Note-taking support

Scribes or readers for tests

Other accommodations

Other Accommodations(Required)

Please describe the other accommodations that you have used to assist you.

What kind of accommodations and supports are you interested in while at Niagara College?(Required)

Niagara College Canada

Forms