Initial Contact Form

City: Zip:

Phone: Home: Your Phone:

E-mail Address:

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).

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:

Please list the accommodations you have received for your disability(ies) and the dates or grades in which you received them (beginning with your most recent accommodations).

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:
Housing Meal Plan Parking