Glendon Accessibility Services Registration Form

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.

***If you are only enrolled for the Fall/Winter term 2020-2021, we will contact you in July/August to set up your initial 2 hours appointment. If you are enrolled in Summer term courses, we will be in contact with you within 3 to 4 days.***

Before we begin, how did you find out about Accessibility Services? *
Section I: As A "New" Student Registering with 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? *
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
You are almost done!

Check off the box below to indicate that you have read (and are aware that you can print a copy for your records) "Academic Accommodation for Students with Disabilities (Guidelines, Procedures and Definitions)" *

You are almost done!

Check off the box below to indicate that you have read (and are aware that you can print a copy for your records) "Academic Accommodation for Students with Disabilities (Guidelines, Procedures and Definitions)" I have read Academic Accommodation for Students with Disabilities (Guidelines, Procedures and Definitions)
Check off the box below to indicate that you have read (and are aware that you can print a copy for your records) "Privacy and Information Practices" *

Check off the box below to indicate that you have read (and are aware that you can print a copy for your records) "Privacy and Information Practices" I have read Privacy and Information Practices