ACCESS Program Registration Form

* indicates a required field

Instructions

This form needs to be completed in one sitting. Your session will time-out after 60 minutes of inactivity, and you will need to re-enter all of your information if this occurs.

The form has a place to upload documentation. If you do not have documentation ready to upload, you can complete the form and submit the documentation later.

Please contact accessibility@lipscomb.edu with any questions about this form, the necessary documentation, or our intake process.

Please use your university issued email address
Classification as of Intake

Specific Accommodation Information

Do you have documentation for your diagnosis/disability?Required

Must be signed by a licensed provider and includes the diagnosis, scope, and relevant testing.

I certify that all the information recorded on this form is true and accurate.Required
I understand that accommodations are granted on a case-by-case basis, and only after a review of the appropriate documentation.Required
I fully understand that it is my responsibility to request the accommodations that I need.
Please read the following Confidentiality and Release of Information Policy.Required

Confidentiality and Release of Information Policy

I have been informed of the policy regarding confidentiality and the release of information from my ACCESS file. I understand that ACCESS may release information from my file to be used in a confidential manner with appropriate University personnel who have a legitimate educational interest while I am a student at Lipscomb.  In addition, if I wish to authorize release of information to parties outside the institution, I will contact ACCESS Program staff.