DRC Application

Before completing this application, please make sure you've read the DRC Handbook.

Name:

Student Number:

Date of Birth: month January February March April May June July August September October November December day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

Gender: Male Female

Marital Status: Married Single

Are you a resident of the State of Utah? Yes No

Are You a Registered Voter? Yes No

Local Information:

Address:

City: State: Zip:

Phone Number:

Permanent Information:

Address:

City: State: Zip:

Phone Number:

Cell Phone Number:

Work Phone Number:

E-mail Address:

Emergency Contact Information:

Name: Phone Number:

High School Information:

High School Attended:

High School GPA:

ACT/SAT Score:

Previous Colleges/Universities Attended:

Please list all previous colleges and universities you have attended in order of attendance from earliest to most recent

USU Information:

Level: level Freshman Sophomore Junior Senior Masters Doctoral

College: college Agriculture Business Education Engineering HASS Natural Resources Science

Major:

Degree Sought: degree sought Certificate Bachelors 2nd Bachelors Masters Doctorate

USU GPA:

Are You Enrolled in Student Support Services? Yes No

Are you a Distance Education Student? Yes No

If "Yes," What is your location?

Funding Sources:

Are you funded by Voc Rehab? Yes No

If "Yes," who is your counselor?

Other Funding Sources

Please list all other funding sources, such as: grants, loans, and scholarships.

How did you learn about the Disability Resource Center?

Do you have a diagnosed disability? Yes No

If "Yes," please describe:

If you do have a diagnosed disability, do you have written documentation of it?

Yes No

If "Yes," when was documentation last received? month January February March April May June July August September October November December

Do you feel you need to be evaluated for a learning problem? Yes No

If "Yes," why?

Are you currently under the care or supervision of a physician psychologist or psychiatrist? Yes No

Do you currently take any medications? Yes No

If "Yes," please list:

Please list all medications you are currently taking.

What services do you feel will be helpful to you?