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Online Student Application

Two easy steps to register
The information gathered on this form allows Kirkwood Community College to work with students in planning effective academic accommodations. Individuals requesting accommodations will be asked to provide supporting documentation of their disability. To start your request for accommodations, please answer the questions below the best you can. If you need assistance or have any questions, contact the Learning Services office at 319-398-5574.
Personal Information
  1. Note: Select when you would like to start your services.
  2. Note: Select when you plan to graduate.
  3. Hint: Enter 8 alpha numeric characters.
  4. Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Contact Information
  1. Hint: Enter 10-digit number only.
  2. Hint: Enter 10-digit number only.
Local Address
  1. Hint: Enter zipcode as 97331 or 97331-0000.
Permanent Address

  1. Hint: Enter zipcode as 97331 or 97331-0000.
Additional Information
  1. Secondary Disability(ies)

    ADHD - 1

    Anxiety Disorders - 2

    Autism Spectrum Disorder - 3

    Blindness, Low Vision - 4

    Chronic Health/Physical - 5

    Deafness, Hard of Hearing - 6

    General Category

    Learning Disability - 7

    Mood Disorders - 8

    Personality/Psychotic Disorders - 9

    Temporary Disability - 11

    Traumatic Brain Injury - 10

  2. Affiliation(s)
  3. Ethnicity(ies)
  4. Campus Location(s)
Questions
  1. Are you requesting accommodations for *
  2. Were you encouraged or referred to seek accommodations? If yes, by who? *
  3. What community agencies are you working with currently? Please select all that apply.
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