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ACCESS Program Registration Form

* indicates a required field

Student Information

Please enter your information

First NameRequired *

Last NameRequired *

Middle Name

L NumberRequired *

Lipscomb EmailRequired *

Please use your university issued email address

Best Phone Number to Reach YouRequired *

SexRequired *

Classification as of Intake

Classification as of Intake New/Transfer Student Classification as of Intake Freshman Classification as of Intake Sophomore Classification as of Intake Junior Classification as of Intake Senior Classification as of Intake Graduate Student Classification as of Intake Dual Enrolled/High School

Major or Field of StudyRequired *

When do you expect to graduate?Required *

Specific Accommodation Information

Diagnosis/Type of DisabilityRequired *

How does your disability/diagnosis affect you academically, socially, and/or physically?Required *

What accommodations are you requesting? (i.e. extended time on tests, preferential seating, etc.)Required *

Do you have documentation for your diagnosis/disability?Required *

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

Do you have documentation for your diagnosis/disability? Yes Do you have documentation for your diagnosis/disability? No

Documentation

Please send documentation to accessibility@lipscomb.edu or bring a copy to the ACCESS Offices in the Academic Success Center.

Upload supporting document(s)

I certify that all the information recorded on this form is true and accurate.Required *

I certify that all the information recorded on this form is true and accurate. Yes I certify that all the information recorded on this form is true and accurate. No

I understand that accommodations are granted on a case-by-case basis, and only after a review of the appropriate documentation.Required *

I understand that accommodations are granted on a case-by-case basis, and only after a review of the appropriate documentation. Yes I understand that accommodations are granted on a case-by-case basis, and only after a review of the appropriate documentation. No

I fully understand that it is my responsibility to request the accommodations that I need.

I fully understand that it is my responsibility to request the accommodations that I need. Yes I fully understand that it is my responsibility to request the accommodations that I need. No

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.

Please read the following Confidentiality and Release of Information Policy. Yes Please read the following Confidentiality and Release of Information Policy. No

Document Information

Document TitleRequired *

FileRequired *

Maximum file size: 10240kb

Description