Intake Form — Disability Resource Center

Intake Form

First Name (preferred)

Last Name

Legal Name (if different from preferred)

Pronouns

he/him/his

she/her/hers

they/them/their

Student ID#

Student E-Mail Address

Phone Number

Major

When will you first need academic/classroom accommodations?

Fall 2024
Spring 2025
Summer 2025

If you have ever had academic/classroom accommodations at a previous school, what types of accommodations did you use?

Attach supporting documentation which covers the points of our Documentation Guidelines.

Disclosure

I understand that submitting this form and documentation does not complete the accommodation process. I still need to complete an intake appointment with my assigned coordinator, then request accommodations in my courses.

Are You a Robot?

A Department of STUDENT AFFAIRS

Disability Resource Center

119 Stevenson Hall

University of Louisville

Louisville, Kentucky 40292

Office Hours

M-F 9:00am to 5:00 pm

Phone

tel (502) 852-6938

fax (502) 852-0924

Inclusion Statement

askdrc@louisville.edu

Social Media

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