The Department of Learning and Student Development Services at SUNY Sullivan has been designated as the office on campus for assisting students with disabilities. If you plan to request accommodations for a physical and/or learning disability please complete and return this form as soon as possible. Information you provide here is strictly voluntary and the provision of services is not dependent on completion of this form. The information will be shared only with officials responsible for assisting you in meeting your needs.

Please check the appropriate responses:

1. Do you have a disability that substantially limits one or more major life activity?
   Yes
   No
2. What is the nature of your disability?
   Learning disability
   Mobility impairment
   Visual impairment
   Hearing impairment
   Other (please describe)
3. What accommodations, including academic support, will you need as a student at SUNY Sullivan?
   
4. Will you be receiving assistance from any outside agencies? If so, please specify.
   
5. What is your home address? Please include city, state, and zip code.