OKCU Disability Information Form

Please fill out the form below completely to register with OKCU's Disability and Access Services. The purpose of accommodations is to provide equal access to the University's programs and activities. Therefore, it is important that you provide documentation of a substantial limitation in a major life activity to obtain accommodations.

Personal Information

Start Term *:
Note: Select when you would like to start your services.
Expected Graduation Term:
Note: Select when you plan to graduate.
First Name *:
Last Name *:
Middle Name:
Optional: Preferred Name:
Student ID *:
Hint: Enter your B Number, starting with B000.
Birth Date:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Gender *:
Pronouns:

Contact Information

Primary Phone Number:
Hint: Enter 10-digit number only.
Secondary Phone Number:
Hint: Enter 10-digit number only.
Email Address *:
Hint: This must be your OKCU email address (username@my.okcu.edu) if you are a current student.

Local Address

Address *:
City *:
State *:
Zipcode *:
Hint: Enter zipcode as 97331 or 97331-0000.

Permanent Address

Same as Local Address

Address:
City:
State:
Zipcode:
Hint: Enter zipcode as 97331 or 97331-0000.

Additional Information

Questions

What is your Primary diagnosis?
Do you have any other diagnoses/disabilities that have a substantial impact on your daily experience?
Please describe the impact of your disability on your educational, living, or other college-related experience. In what ways are you substantially limited? * (Required)
List the accommodations you were approved for and used in high school or at another college/university.
List the accommodations you are currently requesting.
If you are applying for Housing Accommodations please indicate what accommodations you are requesting and why
Have you read the ESA Policy? * (Selection is Required)

Yes

No

Additional Note or Comment
Please identify the type of documentation you will be submitting:

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Disability Services

Oklahoma City University
2501 N Blackwelder, Dulaney-Browne Library 106C
Oklahoma City, OK 73106-1493

Website: http://www.okcu.edu/campus/resources/disability
Email Us: DAS@okcu.edu

Phone: (405) 208 - 5895
Fax: (405) 208 - 5894

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