Student intake form

Before filling out this form, you must first apply and be accepted to Northwestern College. After you have been notified of your acceptance, you may then provide us with documentation of your disability. Information included in this request will be treated as confidential information. Even if you are submitting additional documentation along with the request, it is important you respond to all the questions as best you can. If you need assistance, please seek help from Northwestern’s disability services office.

Personal information

Please provide your name and personal information.

Attention deficit hyperactivity disorder (ADHD)
Blindness or visual Impairment
Deafness or hearing impairment
Head/traumatic brain injury (TBI)
Learning disabilities (LD)
Physical disabilities and/or systemic illnesses
Psychological/psychiatric disabilities
Other (please specify)

By filling out this form, you are initiating your request to be established as a student with a disability in accordance with federal and state regulations.

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