Accessibility Services Intake Form | Grays Harbor College

Grays Harbor College, 1620 Edward P. Smith Drive, Aberdeen, WA 98520-7599
Phone: (Voice) 360.538.4099 (Fax) 360.538.4004

Current Date

Personal Information

Name(Required)

First Last

ctclink Student ID number(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

Gender(Required)

Male

Female

Trans

Non-binary

Prefer not to disclose

Prefer to self describe

E-mail Address(Required)

Phone(Required)

Alternate Phone Number

Is it okay to leave a message at either of these numbers?(Required)

Yes

What is your educational goal?(Required)

Disability Information

Briefly describe your disability and how your disability may impact your education:(Required)

Check areas where you feel your disability impacts you the most:(Required)

Other

Do you have any side effects from medication which impacts your academic performance?(Required)

Yes

If yes, please describe:

Release of Information/Confidentiality/Affidavit

AAS keeps a record of disability documentation. AS will ensure that disability-related documents are kept confidential and shared with college personnel on a limited and need-to-know basis only. Your information cannot be released to anyone not employed by Grays Harbor College without your signed permission on an “Authorization for Release of Information” form.

There are special circumstances under which the agreement of confidentially may be broken:

When a student discloses possible abuse or neglect of a child or incapacitated adult.
When a student discloses that s/he is a threat to self or others.
When a student’s records are legally subpoenaed.

My signature below denotes the information provided on this form is to the best of my knowledge, accurate and true, and that I understand the exceptions to confidentiality.

Student Signature(Required)

Date(Required)

Completing this Intake Form does not determine a student’s eligibility for Accessibility Services. Students may be asked to provide documentation of a diagnosed disability before qualifying for Accessibility Services. Learn more about documentation guidelines (www.ghc.edu/dss/documentation-guidelines)

In addition to completing the Intake Form and providing documentation, students will also need to complete an Intake Interview either in person or virtually with the Accessibility Services Coordinator. To schedule an Intake Interview, call 360.538.4099, 360.538.4143, or email accessibility@ghc.edu

For Accessibility Service Office Use Only:
Accessibility Services Coordinator verifies that they have shared and discussed with student the following documents (Please initial and write the date): Reasonable Accommodations – Appeals Procedures Student Responsibilities