Glendon Accessibility Service Registration Form

Glendon Accessibility Service Registration Form

Welcome to Glendon Accessibility, Well-Being and Counselling (AWC) Centre! We are looking forward to working with you!

Please complete this registration form once you have accepted an offer of admission form and been admitted to York University Glendon Campus. Please note, you will not be able to submit this form without uploading your disability related documentation.

Keele Students should contact Counselling and Disability Services at Keele. Please see their website for contact information: CDS KEELE

The information below will help us to determine what needs and supports you may need while you study at Glendon.This form will likely take 30 to 40 minutes to complete.

Your disability related documentation must be uploaded to this questionnaire (information about how to do this is provided below). We are usually able to set up an initial meeting with a accessibility counsellor within 2-3 weeks of receiving a completed questionnaire and all relevant medical/psychological documentation.

If you have not heard from us within 3-4 business days of submitting your registration information, please email counselling@glendon.yorku.ca or call 416-487-6709.

Before we begin, how did you find out about Accessibility Services? *
Section I: Student Demographics

Tell us a little about yourself and provide your contact information
Name Name * First Last
York Student Number *
Date of Birth Date of Birth * / MM / DD YYYY
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please provide us with your preferred email - one that you check regularly.

This email does not have to be your York email. However, please note that HOTMAIL accounts/messages often get flagged as junk mail and messages can be lost. *
Home Phone Home Phone * - ### - ### ####
Cell Phone Cell Phone - ### - ### ####
Please tell us where we can leave a voice mail (check all that apply): *

Please tell us where we can leave a voice mail (check all that apply): Home Phone Cell Phone Other Other
Check any that might apply to you:

Check any that might apply to you: I am an international student I am a mature student I am a Varsity Athlete currently playing on the following varsity level team (please indicate which sport)
Name of an emergency contact Name of an emergency contact * First Last
The relationship of your emergency contact to you: *
Phone number of emergency contact Phone number of emergency contact * - ### - ### ####
Section II: Nature of disability

Some students have more than one disability. Please check all those which might apply to you.
The nature of my disability is: *

The nature of my disability is: ADHD Learning Disability Austism Spectrum Disorder/Aspergers Mental Health Disability Physcial, Sensory or medical Disability Other-Please specify Other-Please specify
If you checked off more than one disability above, please let us know which disability you feel impacts your ACADEMIC performance the most.

In the box below indicate the nature of the disability where you feel you might need the most accommodations and supports?
Section III Medical/Psychological Documentation-What you NEED to submit

As part of the process of registering with Accessibility Services, you need to provide medical/psychological documentation which will help us to set appropriate accommodations.

If you have not already done so, find out about the kinds of medical/psychological documentation you need to submit for various types of disabilities below.
Select a link(s) to learn about documentation requirements

Select a link(s) to learn about documentation requirements Autism Spectrum Disorder/Aspergers Learnign Disability ADHD Mental Health Disability Physical, Sensory, Medical Disability
PLEASE NOTE:
We cannot set up an initial meeting with the accessibility counsellor until we have BOTH this completed questionnaire AND your medical/psychological documentation. To submit this questionnaire, your disability related documentation must be attached.

It is during your meeting with a accessibility counsellor that your individual accommodation plan will be developed and any necessary documentation that you might require from us can be produced.
Section IV Documentation Upload
Please attach/upload an electronic copy of your medical/psychological documentation here in PDF or Word format.

If you do not have a scanner/electronic copy of your documentation, you can use your phone to take a picture and then convert it with an APP like iScanner or CamScanner.

If it is not possible to attach an electronic copy of your medical/psychological documentation to this questionnaire, please email counselling@glendon.yorku.ca or call 416-487-6709 *

Attach Files
Date completed: Date completed: / MM / DD YYYY
We look forward to meeting you!

Students should complete this questionnaire as soon as they enroll or realize they need supports.

Ideally, students come to see us the term BEFORE they start classes.

For example, we encourage students to come in during the summer for the fall term so we have time to put your accommodations in place.

PLEASE NOTE: We cannot set your first appointment until we have both this questionnaire AND your documentation.

If you will need accommodations to attend your first appointment, please tell us what you will require:

Please note that the AWC center is closed from mid-June to mid-August.
We send limited but crucial information to students periodically by email about deadlines, important events, etc.

Would you like to be notified of important deadlines, reminders and activities through the Glendon Accessibility Services Email Listserve?

Only Glendon or Keele Accessibility/Disability Services can send email to you via the ListServe. *

We send limited but crucial information to students periodically by email about deadlines, important events, etc.

Would you like to be notified of important deadlines, reminders and activities through the Glendon Accessibility Services Email Listserve?

Only Glendon or Keele Accessibility/Disability Services can send email to you via the ListServe. Yes No
Section V Information About You As A "New" Student Registering with Accessibility Services
When do you expect to start your studies at Glendon Campus? *

When do you expect to start your studies at Glendon Campus? Summer 2018 Fall 2018 Winter 2019 I am currently York Student. I started my studies in (e.g. fall 2016)
Level of study *

Level of study Undergrad Masters PhD Certificate
Year of Study at York *
Major *
Will you be living on campus?

Will you be living on campus? Yes No
Do you require assistance getting around the campus?

Do you require assistance getting around the campus? No Yes- Please explain Yes- Please explain
Do you require Attendant Care services?

Do you require Attendant Care services? No Yes-Please explain Yes-Please explain
Section VI Strengths, Challenges and Goals

We'd like to help build your strengths. Please tell us more about your goals, strengths and areas you'd still like to work on.
What are your academic goals? *
What do you see as your academic strengths? *
What strategies do you use to be successful academically? *
What are your academic challenges? *
What strategies do you use to cope with your academic challenges? *
How many courses are you currently enrolled or planning to enroll in? *
What academic accommodations do you think you might require at York? *
Section VII Career Goals

We want to get a sense of where you might be headed. Fill in this section to the best of your ability knowing that you might change course and direction while you are here.
I am coming from: *

I am coming from: High School College Another University Work Force I am currently a York Student Other Other
Did you have access to academic accommodations in high school or in elementary school or another setting? If so, which ones did you use? *
Have you used any computer technology or disability assistive software to support you with your studies? If yes, list the technologies you have used *
How did you do academically in high school? *
Have you attended any other post-secondary schools? If so, please name them, indicating the years you were there and the courses, diplomas or degrees you completed:
Please tell us how you did academically at your other post-secondary schools.
Do you feel your disability has affected your academic performance and educational goals? If so, how? *
Are you currently or have you ever been on academic warning at York or another university? *

Are you currently or have you ever been on academic warning at York or another university? Yes No
If so, when?
Please Note: Actual accommodations will be set with you at your initial meeting and will be based on the specific medical/psychological documentation you provide to us and the core essential requirements of a course.

Accommodations are highly individualized.

At no time can academic accommodations breech academic integrity.

What academic supports or services are most important for you at the university level? Please check all those that apply. *

Please Note: Actual accommodations will be set with you at your initial meeting and will be based on the specific medical/psychological documentation you provide to us and the core essential requirements of a course.

Accommodations are highly individualized.

At no time can academic accommodations breech academic integrity.

What academic supports or services are most important for you at the university level? Please check all those that apply. extra time on test/exams use of a computer the support of resource staff/accessibility counsellors the support of parents assistive technology access to workshops on time management, writing, reading on-going contact with a accessibility counsellor information about financial supports specifically for students with disabilities Other Other
What other academic supports or services do you think you will require at York?
Do you have social or support programs in place currently outside of campus supports *
How is your education being funded? (e.g. OSAP, scholarship)? *
Your accessibility counsellor provides you with educational support not personal counselling or crisis work, what are your expectations of our program?
What is the one thing that concerns you most as you start this academic term? *
How prepared are you feeling with respect to starting courses at university? *

How prepared are you feeling with respect to starting courses at university? Extremely prepared - I understand the campus, supports available to me , and the academic demands of my courses and have the skills that I need to be successful. Somewhat prepared - I think I can navigate the campus, I understand what supports I need and what the academic demands will be but will likely need further support I am very concerned about starting courses, I am uncertain what supports I can access, where to access them, or what my professors will be expecting Other Other
What would a successful year look like for you? *
Is there anything else you feel it would be helpful for us to know?
Consent to Disclose/Discuss Academic Accommodations

There may be occasions when groups or individuals external to Accessibility Services, including Course Directors, TA's, staff in Alternate Exam & Test Scheduling and staff in Library Accessibility Services, may need to discuss your academic accommodations.

Alternate Exam & Test Scheduling is responsible for the scheduling and invigilation of accommodated tests and exams written by students registered with Accessibility Services. Alternate Exam & Test Scheduling is part of the department of Students Affairs.

Library Accessibility Services provides textbooks and other print materials to students registered with Accessibility Services in alternate formats (e.g. electronic). They also provide the door access code to room 134 (a work and study space in Scott Library, Keele Campus, designated only for students with disabilities).

There may be occasions when your course directors will want to discuss the disability-related rationale for your academic accommodations.

Your specific disability diagnosis will NOT be disclosed to any person outside of Accessibility Services (including those listed above) without further consent from you.

Please note: consents granted below can be rescinded at any time by contacting your Accessibility counsellor.
I hereby give Accessibility Services consent to provide and discuss my test/exam accommodations with Alternate Exam & Test Scheduling. *

I hereby give Accessibility Services consent to provide and discuss my test/exam accommodations with Alternate Exam & Test Scheduling. Yes No I would like to discuss further before making a decision
I hereby give Accessibility Services consent to discuss my accommodations with Library Accessibility Services *

I hereby give Accessibility Services consent to discuss my accommodations with Library Accessibility Services Yes No I would like to discuss further before making a decision
I hereby give Accessibility Services consent to discuss my academic accommodations with course directors/TAs. *

I hereby give Accessibility Services consent to discuss my academic accommodations with course directors/TAs. Yes No I would like to discuss further before making a decision
Draw your signature into the box below.

Clear