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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.

All communication from our office regarding this application will be sent to your Samford email address. Please reach out if you have any questions on the status of your application.
Personal Information
  1. Note: Select when you would like to start your services.
  2. Hint: Please enter 9-Digit student ID.
Contact Information
  1. Hint: Please enter your Samford email address.
Additional Information
  1. Secondary Disability(ies)

    Cognitive Impairments

    Medical Disabilities

    Not Determined

    Psychiatric Disabilities

    Sensory/Mobility Impairments

Questions

  1.  

    Medical

    This form is being completed by the student named in the application or by the student AND another individual personally assisting that student. * (Selection is Required)
  2.  

    Academic

    I am requesting academic accommodations. * (Selection is Required)
  3.  
    What academic areas are impacted by your disability or health condition?
  4.  
    Have you previously had access to academic accommodations in high school or college?
  5.  
    Would you like to set up free one-on-one conversations with our office to talk about navigating Samford, accessing resources, self-advocating, making social connections, etc.?
  6.  
    Would you like to set up free one-on-one academic coaching sessions with the Academic Success Center? (organization, time-management, study skills, notetaking strategies, test-taking strategies)
  7.  
    Are you interested in learning more about the on-campus writing center (free one-on-one tutoring for oral and written assignments)?
  8.  

    Community Housing & Meal Plan

    I am requesting housing or meal plan accommodations. (Note: The deadline by which housing accommodations should be approved is June 1 for entering freshman or transfer students). * (Selection is Required)
  9.  
    What areas of the living environment are impacted by your disability or health condition?
  10.  

    Environmental

    I am requesting environmental accommodations. * (Selection is Required)
  11.  
    What environmental areas are impacted by your disability or medical condition?
  12.  

    Wellness

    Would you like to learn more about free on-campus counseling services?
  13.  
    Would you like to learn more about the on-campus food pantry?
  14.  
    Are you currently experiencing extenuating circumstances (financial, grief, family or personal situation)?
  15.  
    I am aware that all members of the OAA staff are mandatory reporters and required by Samford's Sexual Misconduct Policy to report information related to sexual misconduct to the University's Title IX Coordinator. Information on non-mandated reporters on campus can be found here: https://www.samford.edu/departments/student-support/ * (Selection is Required)
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