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Accessibility Services Request Form

This form is voluntary. The more information that is provided to us, the better we will be able to serve you. This form will be submitted directly to the disability contact person in the Student Services office.

Your Info

Name Student ID Number

Street Address

City State Zip Code

Home Phone Alternate Phone

Email Address *Required Entry

Disability (Please check all that apply)

Attention Deficit Hyperactivity Disorder
Back Injuries
Cancer 
Chronic Fatigue Syndrome
Chronic Pain
Depression
Diabetes
Environmental Illness
Fibromyalgia
Hearing Impairment
Hemophilia
HIV/AIDS
Kidney Disease
Learning Disability
Lupus
Mobility Impairment
Psychological Impairment
Sickle Cell Anemia
Speech Impairment
Systemic Diseases
Traumatic Head Injuries
Visual Impairment
Other

You can also print this form and have it mailed to:

Student Affairs/Disability Application
University of Wisconsin-Fox Valley
1478 Midway Road
Menasha, WI 54952

Should you have any other questions, please contact Tina Koch at Tina.Koch@uwc.edu or 920.832.2620