Disability and Access Services Student Intake Form

* indicates a required field

Applicant Information

This form is to be completed by the student. If assistance is needed, please ask a Disability and Access Services Counselor to help. Fill out the form as completely as possible prior to meeting with a Disability Counselor.

Please note, documentation of your disability is required for completion of this form. Please view our Documentation Guidelines for assistance.

Please use your CPCC issued email address
  

Central Piedmont programs

Select the college programs you are involved in

Educational Experience/Background

Degree Completed
Have you ever attended another college or university?

Central Piedmont Information

Are you currently taking classes at Central Piedmont?Required

Veteran Status

Are you a Veteran?Required
Are you a dependent of a Veteran?Required
Are you in the Military Reserve currently?Required
Have you been connected to the Military Families and Veteran Services?Required

Declared Disability

According to the Americans with Disabilities Act a disability is defined as “a physical or mental impairment that substantially limits one or more of the major life activities of such individual; including people with a record of such an impairment or are regarded as having such an impairment”.
Disability Categories Required
Check all that apply and specify
i.e., barriers in the classroom, testing, on campus, etc.
Include name of medication prescribed
Check any of the following outside agencies from which you have received support
Which of the following tasks do you HAVE DIFFICULTY doing?Required
Check all that apply

Accommodation Request

NOTE: Accommodations are approved based on the supporting documentation you provide, an intake interview with a counselor, AND a group staffing decision by the Disability and Access Services team.
Please read and agree to the following statements. Ask questions if neededRequired

My signature affirms that I am registering with Central Piedmont Disability and Access Services as a student with a disability as defined by the Americans with Disabilities Act and Section 504. I understand that despite my disability:

  • I must meet the minimum/technical standards as set forth by my program of study and the classes I take with or without accommodations.
  • I am responsible for following the college’s policies and the Central Piedmont Student Code of Conduct– (if you need a printed copy, please contact disability and access services counselor).
  • Complaints about accommodations should be submitted to the assigned Disability and Access Services counselor
  
Upload supporting document(s)Required

Documentation Guidelines