Name:

Preferred Name:

Select Semester of Enrollment: Fall Semester 2002 Spring Semester 2003 Fall Semester 2003 Spring Semester 2004 Fall Semester 2004 Spring Semester 2005 Fall Semester 2005 Spring Semester 2006

Home Address:

City:

State:

Zip Code:

Home Phone#

Work Phone#

Social Security#

Email Address:

Please describe briefly the nature of your disability. If your disability affects your ability to participate in, obtain equal access to, or receive benefits from the educational programs and activities that are offered by the University of Wisconsin Oshkosh, please describe.

What auxiliary aids, specific accommodations, or academic adjustments are necessary in order for you to participate in, obtain equal access to, or receive benefits from the educational programs and activities that are offered by the University of Wisconsin Oshkosh?  If so, please provide official documentation regarding your disability and official verification of the need for the specific accommodation requested.

Have you been in contact with the Division of Vocational Rehabilitation (DVR), Wisconsin Department of Health and Social Services? If so, please list the name, address, and the phone number of your counselor at DVR.

As evidenced by signature which is affixed below, I hereby authorize and request the exchange of information, records, and documentation between my counselor at the Division of Vocational Rehabilitation, learning disabilities specialist, psychologist, psychiatrist, physician, or other health care specialist and the Dean of Students Office at the University of Wisconsin Oshkosh.  I further request these offices to discuss my personal, medical, and educational needs as they may relate to my enrollment or participation in course, programs or activities offered by the University of Wisconsin Oshkosh.

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Today's Date: