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Online Student Application

Two easy steps to register
Welcome to the PNW Accessibility's online request form for PNW Accessibility 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.
  8. Hint: Enter 9 alpha numeric characters.
  9. 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
  4. Hint: Enter zipcode as 97331 or 97331-0000.
Permanent Address

  4. Hint: Enter zipcode as 97331 or 97331-0000.
Additional Information
  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

Questions

  2.  
    Choose any individual diagnosis(es):
  3.  
    Choose any chronic health diagnosis(es):
  4.  
    Choose any learning disability diagnosis(es):
  5.  
    Choose any injury dignosis(es):
  6.  
    Choose any psychological/mental health diagnosis(es):
  7.  
    Choose any traumatic brain injury/neurological impairment diagnosis(es):
  8.  
    Check off any functional limitations:

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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