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.

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.

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
Pronouns
Date of Birth Date of Birth * / MM / DD YYYY
York Student Number *
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. *
Student's cell phone number: Student's cell phone number: * - ### - ### ####
Can we leave a message at this number *

Can we leave a message at this number Yes No
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 Learnign Disability Autism Spectrum Disorder/Aspergers Mental Health Disability Physical, Sensory, 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 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
Please check the circumstance that best describes you: *

Please check the circumstance that best describes you: I have a diagnosed disability and have attached a completed Medical Form or a psychoeducational or neuropsychological assessment. I have a diagnosed disability and have attached some documentation to verify (e.g. the OSAP Disability Verificaiton Form or an Individualized Education Plan). I have a diagnosed disability but do not currently have any documentation and am in the process of obtaining it I suspect I have a disability and have been referred to be assessed I suspect I have a disability and would like to explore assessment option
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.

If you will need accommodations to attend your first appointment, please tell us what you will require:
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 IV 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)
I am coming from: *

I am coming from: High School College Another University Work Force I am currently a York Student Other Other
Level of study *

Level of study Undergrad Masters PhD Certificate
Year of Study at York *
Major *
How many courses are you currently enrolled or planning to enroll in? *
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 V 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? *
Maximum of 500 characters allowed. Currently Entered: 0 characters.
What do you see as your academic strengths? *
What strategies do you use to be successful academically? *
Please describe how the nature of your disability impacts you. What are the functional limitations that you experience and how do these impair your academic functioning *
What strategies do you use to cope with your academic challenges? *
Section VI 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.
What are your career goals? *
What support do you feel would be helpful to assist you with developing or achieving your career goals? *
Section VII, Supports

Students need access to a variety of supports while they are students. This section will help us to determine what you have had in the past, what supports you might currently have in place and where we might be able to make suggestions for further support.
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? *
Maximum of 500 characters allowed. Currently Entered: 0 characters.
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?
What academic accommodations do you think you might require at York?

Please Note: Accommodations are highly individualized. 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. At no time can academic accommodations breech academic integrity.

Please check all those that apply: *

What academic accommodations do you think you might require at York?

Please Note: Accommodations are highly individualized. 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. At no time can academic accommodations breech academic integrity.

Please check all those that apply: extra time on test/exams use of a computer to write tests/exams the support of resource staff/accessibility counsellors access to assistive technology writing tests/exams in a distraction reduced environment note taking support Other Other
Do you have social or support programs in place currently outside of campus supports *
How is your education being funded? (e.g. OSAP, scholarship)? *
Since we provide educational support not personal counselling or crisis work, what are your expectations of our program?
What is the one thing that concerns you the most as you start this academic term? *
Maximum of 500 characters allowed. Currently Entered: 0 characters.
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? *
Maximum of 500 characters allowed. Currently Entered: 0 characters.
Is there anything else you feel it would be helpful for us to know?
Maximum of 500 characters allowed. Currently Entered: 0 characters.
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

Glendon Accessibility Service Registration Form

Glendon Accessibility Service Registration Form

Section I: Student Demographics

Section II: Nature of disability Some students have more than one disability. Please check all those which might apply to you.

Section III Documentation Upload

Section IV Information About You As A "New" Student Registering with Accessibility Services

Section V Strengths, Challenges and Goals

Section VI Career Goals

Section VII, Supports

Consent to Disclose/Discuss Academic Accommodations

Section II: Nature of disability

Some students have more than one disability. Please check all those which might apply to you.