subject_line
UCNJ Universal Accessibility Services
Application for Accommodations
First Name
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Last Name
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MI
UCNJ Student ID#
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Address 1
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Address 2
City
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State
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Zip Code
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Phone #:
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UCNJ Email address @owl.ucc.edu
Personal Email Address:
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Date of Birth
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Major
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Status
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New Student
Current Student
Returning Student
Transfer Student
Visiting Student
Semester and Year that you are applying for:
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Fall
Spring
Summer
Year
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Background Information
High School
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City
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State
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I attended high school outside of the United States
Yes
Year Graduated
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Which best describes your high school experience?
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Fully Mainstreamed in all classes (no resource classes)
Mainstreamed with extra teacher in classroom
Used accommodations only (Section 504)
Resource pull-out replacement
Home Schooled
High School GPA
Which best describes your type of disability? (Check all that apply):
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ADHD
Speech Disability
Specific Learning Disability
Blind / Visual Disability
Deaf / Hard of Hearing
Communication Disability
Autism Spectrum Disorder
Orthopedic Disability
Psychiatric / Emotional Disability
Traumatic Brain Injury
Intellectual Disability
Medical Disability
N/A- none of the above (describe below):
N/A- none of the above (describe below):
Please check all of the reasonable accommodations you are requesting. (Please understand that checking an accommodation does not guarantee that you will receive it.)
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extra time for testing
four-function calculator
no scantron forms
permission to record lectures
notetaking assistance software
sign language interpreter
CART services
use of JAWS
reduced distraction testing room
preferential seating
clarification of directions
use of own laptop for notetaking
relaxed absence policy
n/a- none of the above
I don't want accommodations I only want specialized advising
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Yes, I do not want accommodations only specialized advising and support
No, I want to use accommodations with specialized advising and support
Are there any other accommodations not listed above that you would like to request?
My disability may cause me to violate UCNJ code of conduct as found here: https://www.ucc.edu/campus-life/student-handbook/
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Yes
No
Email this to Universal Accessibility Services
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Coordinator
Director
By electronically signing my name, I am acknowledging the submission of the Universal Accessibility Services application and I am requesting a review of my documentation for consideration of accommodations at UCNJ. I understand that I must present current documentation to support this application.
Signature
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clear
Upload your documentation files here.
Upload more documentation here
Upload more documentation here
Thank you for submitting your application. If you are unable to upload your documents, please submit them to:
Coordinator of Universal Accessibility Services
UCNJ
1033 Springfield Avenue
Cranford, NJ 07016
908-659-5168
amanda.nielsen@ucc.edu