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Regional Campus Disability Services

* required fields

  • First Name*


  • Last Name*
  • Street Address*
  • City*
     

  • State*


  • Zip Code*

     
  • Check if local and permanent addresses are the same.

  • Street Address


  • City


  • State


  • Zip Code
     
  • Phone*
  • Kent State Email Address*
     
  • Please release my documentation to: (check all that apply)*

    Kent State University at Ashtabula    
    Kent State University at East Liverpool    
    Kent State University at Geauga    
    Kent State University at Salem    
    Kent State University at Stark    
    Kent State University at Trumbull    
    Kent State University at Tuscarawas    

Disability documentation will be kept in the Student Accessibility Services office and strict confidentiality will be maintained. Student Accessibility Services will not release your documentation without your written permission, except under the provisions of the Family Educational Rights and Privacy Act (FERPA). For additional information on the University's student records policy, please visit the University Registrar website.

  • Specific information to release: (check all that apply)*

    Medical/chronic health disability documentation    
    Psychological assessment including DSM-IV diagnosis    
    Physical/orthopedic and mobility disability documentation    
    Audiogram - hearing test results    
    Vision screening test results    
    Multi-factored Evaluation (MFE) and/or Individualized Education Plan (IEP)    
    BVR Individual Written Rehabilitation Plan (IWRP)    
    Other    
     
  • I accept responsibility for the release of this information.*

  • I understand that this authorization automatically expires one year from the date of submission.*

  • I understand that submitting this form does not complete my registration with the corresponding disability services office indicated above.*

  • I understand that I must contact the coordinator of the corresponding disability services office, indicated above, for further information regarding registration and accommodation procedures.*