EMORY UNIVERSITY
Office of Disability Services
201 Dowman Drive
110 Administration Building
Atlanta, Georgia 30322-0520
Voice: 404/727-9877; TTY: 404/712-2049
Fax: 404/727-1126
SELF-IDENTIFICATION FORM
It is the policy of Emory University to ensure that all University goods, services, facilities, privileges, advantages, and accommodations are meaningfully accessible to qualified persons with disabilities in accordance with the Americans with Disabilities Act (ADA) of 1990, Section 504 of the Rehabilitation Act of 1973, and other pertinent federal, state, and local disability anti-discrimination laws.

Reasonable accommodations will be made on an individual basis.  It is the responsibility of persons with disabilities, however, to seek available assistance and to make any needs known.

If you are an individual with a disability/chronic medical condition who may require assistance or accommodations from Emory University, please complete this form and return to:

Office of Disability Services
201 Dowman Drive, Suite 110
Atlanta, Georgia 30322

Once received, the Office of Disability Services will send an information packet detailing their services provided and all other pertinent information ( i.e., required medical documentation, intake appointments and the menu of general accommodations available).

No disclosure of this information will be provided without your consent.  We guarantee confidentiality.

C Please cut along this line and retain the top portion of this form for your reference.

Name:_________________________________________________________		Indicate your disability category:
										⁪ Sensory (i.e. Visual, Hearing, etc.)
Address:_______________________________________________________		⁪ Psychological/ Emotional
										⁪ Learning
City/ State/Zip:_________________________________________________		⁪ Chronic Medical Condition

Telephone: (____)_______________________________________________

SS#:________-________-_______or Student ID_______________________

Please mark the appropriate school:

⁪ Emory College			⁪Candler School of Theology 		⁪ Goizueta Business School
⁪ Oxford College		⁪ Woodruff School of Nursing		⁪ Rollins School of Public Health
⁪ Law School			⁪ Graduate School of Arts & Sciences	⁪ School of Medicine
⁪ Allied Health

Enrollment date:

⁪ Fall 20__        	 ⁪ Spring 20__        	 ⁪ 1st Term Summer 20__        	 ⁪ 2nd Term Summer 20__
 	
Expected Graduation Year: ____________		      

REVISED 10/08:ODSSTAFFFOLDER/CURRENT FORMS/SELF IDENTIFICATION	

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Office of Disability Services
Emory University
201 Dowman Drive
110 University Administration Building
Atlanta, Georgia 30322-0520

Attn: New Student Coordinator

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