Confidential Intake Form (Student Accessibility Services)

This form is to be completed by any student who is new to Student Accessibility Services (SAS) and will be used to connect you with an Accessibility Strategist. Complete this form if you have a permanent or temporary disability, or had an Individual Education Plan (IEP) in high school. It is the first step in accessing supports and accommodations available at Confederation College.

Please note: Medical documentation listing the functional limitations of a permanent or temporary disability is required.

Contact Information

First Name

Last Name

Confederation College Student Number (if known)

Address

City

Province/Area

Postal /Zip Code

E-mail Address

Phone Number

Gender

Year of Birth

Best way to contact you?

Academics

Confederation College Program?

Accepted?

I have been accepted into this program

I am planning to apply to this program

Documentation

I currently have documentation of my disability/medical condition?

Yes

** OPTIONAL – Provide the nature of your disability or medical condition:

I am in the process of getting documentation of my disability/medical condition?

Yes

Funding

Funding Source(s):

OSAP

Second Career

WSIB

Other Funding Source (Specify):

Notes

Please NOTE

Please note: Completing this form is the FIRST step in identifying your disability needs with Student Accessibility Services.

Follow-up appointments are required to ensure supports are put in place. Your involvement in the process is necessary.

Freedom of Information & Protection of Individual Privacy Act Disclaimer

The personal information requested on this form is collected in accordance with Section 42 of the Freedom of Information and Protection of Individual Privacy Act. The information provided will be used by Student Accessibility Services to contact students, determine accommodations and services, and report statistics. Should you have any questions concerning your personal information please contact the Privacy Officer at (807) 475-6267. Confederation College is committed to the protection of the personal privacy of all individuals.

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Confidential Intake Form (Student Accessibility Services)

Freedom of Information & Protection of Individual Privacy Act Disclaimer