DRC Application

Note: After submitting the form, you might get an error. This is a problem with redirecting to another webpage. We are currently working on this. Your form will still be submitted, so disregard the error.

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

Name:

Student Number:

Date of Birth:

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:

USU Information:

Level:

College:

Major:

Degree Sought:

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

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?

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:

What services do you feel will be helpful to you?