Accessibility Services Self-Identification Form

If you are a student with a permanent or temporary disability and you may require academic accommodations to support your learning at Nipissing, please complete and submit the following form as soon as possible.

Note: Upon receiving this completed form, Student Accessibility Services will contact you to begin the intake process.

If you have any questions regarding this self-identification process or general inquires, please contact Student Accessibility Services by email, sas@nipissingu.ca or phone, 705.474.3450 ext. 4362

Contact Information

Name I Use

First Name

Last Name

Student ID #

Pronoun

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Telephone #

Alternate Telephone #

Email Address

Nipissing Email Address

Program of Study

Degree Program / Major

Campus

Are you applying as a...

High school student

College/University Transfer Student

Mature Student

Distance Education Student

Does your program have a placement requirement (e.g. nursing, education, etc.) for which you may require accommodations?

Yes, my program has a placement requirement which I may require accommodations.

No, my program does not have a placement requirement.

Protection of Privacy:

The information on this form is collected under the authority of the Nipissing University Act, 1992. It is related to and needed by the University to provide services and support disability-related accommodation requests for students with disabilities. The information will be used by employees of the Counselling and Student Accessibility Services Office and will not be disclosed to any third party without your written consent. If you have any questions about the collection, use and disclosure of this information, please contact the Manager of Student Accessibility Services, Nipissing University, 100 College Drive, North Bay ON P1B 8L7, 705.474.3450 ext. 4097.