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Online Student Application

Two easy steps to register
Welcome to the Disability Access Center's online Student Application for Disability Access Center services.

Please complete this form in its entirety so we may serve you better!
Personal Information
  1. Note: Select when you would like to start your services.
  2. Note: Select when you plan to graduate.
  3. Hint: Enter 9 alpha numeric characters.
  4. Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Contact Information
  1. Hint: Enter 10-digit number only.
  2. Hint: Enter 10-digit number only.
Local Address
  1. Hint: Enter zipcode as 97331 or 97331-0000.
Permanent Address
  1. Hint: Enter zipcode as 97331 or 97331-0000.
Additional Information
  1. Secondary Disability(ies)

    General Category

    Mental Health

    Neurological

    Physical Impairment

  2. Affiliation(s)
  3. Ethnicity(ies)
  4. Campus Location(s)
Please check all the accommodations you may have received in the past.

Prior Accommodations

Alternative Testing
Alternative Formats
Deaf and Hard of Hearing
Notetaking Services
Emergency Accommodations
In Class Accommodations
Please check all the accommodations you are requesting to use at Purdue University Northwest that is supported by your documentation. This list is include the most common accommodations. When you meet with DAC staff you may discuss other accommodations that is supported by your documentation.

Requesting Accommodations at DAC

Alternative Testing
Alternative Formats
Deaf and Hard of Hearing
Notetaking Services
Emergency Accommodations
In Class Accommodations
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