Furman University

Initial Contact Form

Contact Information

First Name:
Middle Name:
Last Name:
Address:
City:
State:
Zip:
Phone:	Home Phone Cell Phone Work Phone
Email:
Furman ID #:
Current Class Status:	Incoming Freshman Freshman Sophomore Junior Senior

Disability Information

Please state your diagnosed disability(ies) and age of onset:

Please describe how your disability(ies) affects you inside and outside the classroom. Include information about what has been difficult for you in classes and in everyday life that you believe to be related to your disability(ies).

Functional Limitations

Please check any of the major life activities listed below that you believe are affected by your disability(ies). Please also indicate if you believe the level of limitation you experience as a result of your disability(ies) is mild, moderate or substantial:

Talking None Mild Moderate Substantial Caring for self None Mild Moderate Substantial Concentrating None Mild Moderate Substantial Hearing None Mild Moderate Substantial Walking/Standing None Mild Moderate Substantial Listening None Mild Moderate Substantial Breathing None Mild Moderate Substantial Lifting/Carrying None Mild Moderate Substantial Memorizing None Mild Moderate Substantial Sitting None Mild Moderate Substantial Socializing None Mild Moderate Substantial Reading None Mild Moderate Substantial Eating None Mild Moderate Substantial Learning None Mild Moderate Substantial Calculating None Mild Moderate Substantial Sleeping None Mild Moderate Substantial Taking Exams None Mild Moderate Substantial Writing/Spelling None Mild Moderate Substantial

Accommodations History

	Dates/Grades	Accommodation
1.
2.
3.
4.
5.

Did you receive accommodations for your disability(ies) when taking the SAT or ACT? If so, what were they?

What accommodations do you find most helpful?

What academic accommodations will you be requesting while a student at Furman University?

Other accommodations necessary: HousingMeal PlanParking