Intake Form

* required fields

Student Information
Male Female

Local Mailing Address

Permanent Mailing Address

Transfer Student Background


Pertinent Barry University Information
Fall Spring Summer
Yes No

* Please Check The Specific Condition/Disability For Which You Seek Accommodations
Combined/Predominately Inattentive/Predominately Hyperactive-Impulsive

Outside Agency Information
Yes No

I hereby authorize the Office Disability Services of Barry University to release/receive necessary information deemed relevant to disability accommodation and ODS program eligibility at Barry University. Information may include medical records or reports and/or psychological or psychoeducational assessments/records.


Release of Confidential Information

I hereby authorize release of accommodation memos addressed to my current professors stating my reasonable accommodations, which I will hand deliver. In addition, I give permission to release my academic and/or disability related information contained in my ODS file to the following:




Declaration

Further, I understand that I may amend this agreement at any time in writing and, unless I note otherwise, it will remain in effect until completion of my program at Barry University.

I hereby authorize the Office Disability Services of Barry University to release/receive necessary information deemed relevant to disability accommodation and ODS program eligibility at Barry University.