DSS Student Intake Form

Note: Please use one form per term. Fill out the form below and email documentation of your disability to dss@bowiestate.edu.

DSS Student Intake Form

Student ID Number

First name*

Last name*

Email*

Phone*

Street Address

City

State or Province

ZIP or Postal Code

Classification*

Username*

Major*

Cumulative GPA

Last Term GPA

Emergency Contact Email Address*

Emergency Contact Phone Number*

Disability*Check all that apply and specify if requested

Other DisabilityIf you answered "other" above

Specify Medical/Health

Accommodation Requested*

Acknowledgement of Understanding: Disability records are confidential, maintained in the DSS office and are protected as an educational record under the Family Educational Rights and Privacy Act (FERPA). Disability-related information may be disclosed on a limited, need-to-know basis in order to provide accommodations and services with the permission of the student or as otherwise permitted under the University’s policy. Appropriate disability documentation supporting the requested accommodations/services must be submitted to DSS office in order for the registration to be processed. The documentation provided will be reviewed as a part of a collaborative process with the student. An interactive process will be scheduled once the application and appropriate documentation are received. Accommodations received at another institution are not binding on Bowie State University. DSS may propose an alternative accommodation that would be appropriate but has not been recommended in the past or the student has not received.*

yes

I will email supporting documentation to dss@bowiestate.edu to complete this request.*

Yes