Application For Services - Office of Disability Services
  1. This information is required in order to assist in determining your eligibility for services through the Office of Disability Services. All information is strictly confidential and cannot be shared without your permission. In order for the ODS Director or the Assistant Director to exchange information regarding your disability with any faculty, staff, or agency, you must also sign a RELEASE OF INFORMATION FORM in the ODS office. Please answer all questions!
  2. Full Name(*)
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  3. Date of Birth(*)
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  4. Sex(*)
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  5. T#(*)
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  6. TTU E-Mail
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  7. Local Address: (Please Residential Hall/Tech Village)
  8. Address Line 1(*)
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  9. Address Line 2
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    If applicable
  10. City(*)
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  11. State(*)
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  12. Zip(*)
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  13. Permanent Address:
  14. Address Line 1(*)
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  15. Address Line 2
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    If applicable
  16. City(*)
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  17. State(*)
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  18. Zip(*)
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  19. Phone Numbers:
  20. Local Phone (Cookeville or TTU)
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    xxx-xxx-xxxx
  21. Phone - Permanent(*)
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  22. Cell
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  23. Academic Classification(*)
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  24. Major(*)
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  25. Current GPA
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  26. Are you a Veteran?(*)
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  27. Do you receive services from any agency such as Vocational Rehabilitation, Social Security, VA, etc.?(*)
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  28. If YES, please provide agency or contact information on Release of Information Form under Other Agencies.
  29. Type of Disability(*)
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    Please be specific - Give the name
  30. Date of Diagnosis(*)
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  31. Current Medications(*)
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  32. Are you currently receiving treatment?(*)
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  33. Please provide information about the certified medical/psychological professional who best knows about your disability:
  34. Name
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  35. Address Line 1
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  36. Address Line 2
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    If applicable
  37. City
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  38. State
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  39. Zip
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  40. Phone
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  41. Academic or other problems caused by your disability (be specific)(*)
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  42. Academic or other Adjustments Requested(*)









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  43. If you checked 'Other' - Please Specify
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  44. *Professionals in the Office of Disability Services will determine whether current documentation supports your request.
  45. *Disability Housing Requests require a housing application through Residential Life
  46. * Please remember you are required to register and meet with the Office of Disability Services.

    I verify that the above information is correct to the best of my knowledge. I understand that I am to supply current documentation (see specific documentation requirements) of my disability in order to determine if I qualify for services. Completion of this application does not ensure academic adjustment. Adjustments are based on review of documentation specific for each disability and its impact and functional limitations.

  47. Initial For Applicants Electronic Signature(*)
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  48. Date(*)
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  49. Submit
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