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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: Please select campus location where you will be enrolled.
  3. Note: Select when you plan to graduate.
  4. Hint: Enter 9 alpha numeric characters.
  5. 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. Functional Limitation(s) *
  2. Affiliation(s)
  3. Ethnicity(ies)
  4. Campus Location(s)
Please check all the accommodations you may have received in the past.

Prior Accommodations

Testing Accommodations
Alternative Formats
Communication Access
Notetaking Services
Emergency Accommodations
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

Testing Accommodations
Alternative Formats
Communication Access
Notetaking Services
Emergency Accommodations
Class Accommodations
Questions

Legend

Code Description
OFR Online Fully Remote
VC Virtual Classroom: Live LEC
HYB Hybrid: On-Campus + Online
FTF Face-to-Face: In-Person
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