BSC Student Accessibility Application

Please complete this form for the SA office to have on file. If you have any questions, please call 701-224-5671.
Personal Information
* First Name:
 
* Middle Name:
 
* Last Name:
 
* Current Address - Street:
 
Current Address - PO Box
* Current Address - City:
 
* Current Address - State:
 
* Current Address - Zip Code:
 
* BSC Email Address:
 
* Student ID Number:
 
* Cell Phone Number:
 
* Term applying for:
 
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:
 
* Who is the most recent provider to diagnose or treat symptoms related to the disability?:
 
* Please explain how you are affected by the disabilities indicated above:
 
* Please check the area(s) below impacted by those disabilities:











 
* 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):
 
* Please describe the accommodations you are requesting to receive at BSC:
 
What other information would be helpful to the BSC staff to know about you?:
* What are your strengths as a student?
 
* What are your weaknesses as a student?:
 
How were you referred to the Student Accessibility Office:
*
By checking the box, I agree to allow the Associate Dean of Student Affairs, or designee, to determine whether pertinent staff members should be informed of my disability information in order to fully support my needs.
 
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