Student Accessibility Services Intake Form

* indicates a required field

Student Information

Thank you for contacting Student Accessibility Services at Clark University! In order to begin the registration process, please complete the intake form below and attach the appropriate documentation. Documentation should be from a licensed professional that explicitly states your diagnosis, the functional limitations that result from that disability, and accommodation recommendations. Please visit: https://www.clarku.edu/offices/student-accessibility-services/services-and-accommodations/registering-and-documentation/ to learn more about the registration process and documentation guidelines.

First Name

Last Name

Middle Name

Preferred Name

Preferred Pronouns

Student ID

Please use your university issued email address

Phone Number

Specific Accommodation Information

Describe the disability or temporary medical condition in which you are seeking accommodations.

Are you requesting academic accommodations?

Are you requesting campus housing and/or dining accommodations?

Upload supporting document(s)

Documentation should be from a licensed professional that explicitly states your diagnosis, the functional limitations that result from that disability, and accommodation recommendations. Please note documentation must be from within the last three years.

Student Accessibility Services Intake Form

Student Information

Specific Accommodation Information

Document Information