ACCESS Program Registration Form

* indicates a required field

Student Information

Please enter your information
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.