Glendon Accessibility Services Registration Form

Welcome to Glendon Accessibility Services at the 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 and have been admitted to York University Glendon Campus.

Keele Students should contact Student Accessibility Services at Keele. Please see their website for contact information: SAS KEELE

The information below will help us to determine what needs and supports you may need while you study at Glendon College. 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 Glendon Accessibility Services? *
Section I: As A "New" Student Registering with Glendon Accessibility Services

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 *
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. *
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
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
When do you expect to start your studies at Glendon Campus? *

When do you expect to start your studies at Glendon Campus? Summer 2020 Fall 2020 Winter 2021 I am currently York Student. I started my studies in (e.g. fall 2016)
How many courses are you currently enrolled or planning to enroll in? *
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 graduate student I am a visiting student from another univeristy I am a Varsity Athlete currently playing on the following varsity level team (please indicate which sport)
How is your education being funded? (e.g. OSAP, scholarship)? *
Will you be living on campus?

Will you be living on campus? Yes No
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?
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 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
To support the development of an academic accommodation plan, an in-depth understanding of a student’s functional limitations is required. Recent, comprehensive documentation from a registered health professional is integral to the development of an accommodation plan. Limited or interim accommodations will be available to students with older or incomplete (e.g. OSAP Disability Verification Form, IEP) documentation.

Please check the circumstance that best describes you:

To support the development of an academic accommodation plan, an in-depth understanding of a student’s functional limitations is required. Recent, comprehensive documentation from a registered health professional is integral to the development of an accommodation plan. Limited or interim accommodations will be available to students with older or incomplete (e.g. OSAP Disability Verification Form, IEP) documentation.

Please check the circumstance that best describes you: I have attached a completed Medical Form or a recent psychoeducational or neuropsychological assessment (or one that was completed when I was 18+) I have attached a copy af a psychoeducational assessment or neuropsychological assessment that was comlpeted more than 4 years ago I have attached my OSAP Disability Verification Form. I have attached a copy of my Individualized Education Plan (IEP) from high school or a Letter of Accommodation from another post-secondary institution. I have attached a note from a medical practioner.
We look forward to meeting you!

Please let us know your schedule below and we will do our best to schedule your appointment accordingly. The initial appointment will be about 2 hours long.

If you need accommodations (e.g. ASL interpreter) to take part in a registration session, please tell us what you will require.
Section IV : Stregths, Challenges and Goals
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 V Career 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 career goals? *
What support do you feel would be helpful to assist you with developing or achieving your career goals? *
Section VI: 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.
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? *

Did you have access to academic accommodations in high school or in elementary school or another setting? Yes No
If yes, what were the accommodations:

If yes, what were the accommodations: Writing tests/exams in a distraction reduced environment. Extra time to write tests/exams. Use of a computer to write tests/exams. Access to Kurzweil. Access to Dragon. Other Other
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? *

Have you attended any other post-secondary schools? yes no
If yes, please list the schools, indicate the years you were there, the program(s) you were in, whether or not you completed the program and how you did academically:
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?
Which of the following accommodations would address your functional limitations?

Please Note: Accommodations are highly individualized. Actual accommodations will be set as you move through the registration process and will be based on the core essential requirements of the course and our understanding of your functional limitations (the medical/psychological documentation that you have provided is an important part of that understanding). At no time can academic accommodations breech academic integrity.

Please check all those that apply: *

Which of the following accommodations would address your functional limitations?

Please Note: Accommodations are highly individualized. Actual accommodations will be set as you move through the registration process and will be based on the core essential requirements of the course and our understanding of your functional limitations (the medical/psychological documentation that you have provided is an important part of that understanding). 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 (i.e. personal counselling) in place currently outside of campus supports *
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.
What would a successful year look like for you? *
Notification of How Your Information Will Be Used

Glendon Accessibility Services collects medical documentation and other information pertaining to your functional limitations, your history of learning or personal circumstances for the following purposes:

• To verify the need for disability related accommodations for academic work and
• To develop and implement effective disability related accommodations and supports

Glendon Accessibility Services respects your privacy and keeps your information confidential. Information may be shared with university staff, but only on a need-to-know basis to allow them to perform their duties and to provide academic or other disability related accommodations on campus.

Examples:
• Test and Exam accommodations will be shared with the Alternate Exam/Test Scheduling for invigilation.
• The name of students with a reduced course load as an accommodation may be shared for fees adjustment purposes or to arrange bursaries.
• Accessibility Counsellors may speak to a professor, registrar or residence staff to arrange accommodations and supports.
• When a student encounters difficulties that require attention from other University units, such as Student Accessibility Services, Glendon Personal Counselling Services, Student Counselling & Development, Students of Concern Committee, Office of Student Affairs, Residence Life, necessary information is shared with those units.

To protect your information, all university staff receiving information follows University policies and guidelines, the Freedom of Information and Protection of Privacy Act and other legal requirements*.

If you have any questions, please send an email to counselling@glendon.yorku.ca. Your email will be forwarded to the Glendon Accessibility Counsellor and/or the Manager of the Accessibility, Well-Being, and Counselling Centre for follow up as soon as possible.

* Glendon Accessibility Services provides academic accommodation and support to students with disabilities in accordance with the Ontario Human Rights Commission’s Policy on accessible education for students with disabilities and York University Senate Policy on Academic Accommodation for Students with Disabilities.

Glendon Accessibility Services at Glendon College, York University is subject to the Freedom of Information and Protection of Privacy Act ("FIPPA") and York University’s Policy on Access to Information and Protection of Privacy. Information is collected under the authority of The York University Act, 1965 to administer the university-student relationship.
Further information "About How Your Information Will Be Used" is available on our website:
Draw your signature into the box below. By signing this form, you acknowledge that you have read and understand the "Notification of How Your Information Will Be Used". *

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Glendon Accessibility Services Registration Form

Glendon Accessibility Services Registration Form

Section I: As A "New" Student Registering with Glendon Accessibility Services

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 : Stregths, Challenges and Goals

Section V Career Goals

Section VI: Supports

Notification of How Your Information Will Be Used

Section II: Nature of disability

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