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Online Student Application

Two easy steps to register
This application gathers information as part of the evidence needed to determine eligibility for accommodations due to a documented disability, which is defined as 1) being diagnosed with a condition, and 2) experiencing a functional impairment or substantial limitation in at least one major life area. This application should be completed in its entirety by the student. There are no right or wrong answers – just answer each question to the best of your ability and provide thorough information. If you have questions or need assistance completing this application, please contact us. Information provided in this application is confidential and will not be shared with other internal or external entities or departments.
Personal Information
  1. Note: Select when you would like to start your services.
  2. Note: Select when you plan to graduate.
  3. Hint: Please enter 9-Digit student ID.
  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.
  3. Hint: Please enter your Samford email address.
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)

    Cognitive Impairments

    Medical Disabilities

    Not Determined

    Psychiatric Disabilities

    Sensory/Mobility Impairments

  2. Affiliation(s)
  3. Ethnicity(ies)
Please select accommodations and services you have received previously (i.e., in high school via 504/IEP, on standardized tests such as the ACT or SAT, or at another college or university). If there are none, please leave any selections blank.

Prior Accommodations

Alternative Testing
Alternative Formats
Deaf and Hard of Hearing
Notetaking Services
Classroom Access
Please select accommodations you are requesting to receive at Samford. You will have an opportunity to upload supporting documentation to help determine eligibility for accommodations.

Requesting Accommodations at DR

Alternative Testing
Alternative Formats
Deaf and Hard of Hearing
Notetaking Services
Classroom Access
Questions
  1. How did you learn about Disability Resources (check all that apply):
  2. What did the diagnostic process consist of? Check all that apply.
  3. Check the following academic areas in which you have experienced difficulty due to your disability.
  4. Check the following major life activities that are impacted by your disability.
  5. Are you requesting a foreign language course substitution due to disability? (Note: foreign language requirements vary depending upon the major / program). *
  6. Are you requesting accommodations related to the physical activity requirements of your major / program? (Note: University Concepts of Fitness and Health is a Core Curriculum requirement for all students and does involve physical activity). *
  7. Are you requesting housing accommodations (Note: the deadlines by which housing accommodations should be approved are as follows: June 1st for Fall move-in; November 1st for Spring move-in; April 1st for summer move-in). *
  8. Indicate the housing accommodations you are requesting in order to have equal access to the on-campus living environment. Check all that apply.
  9. Are you requesting a meal plan accommodation? *
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