Student [Must be registered with Disabled Student Services]
Faculty/Staff
Other

SUNYCard ID Number: (example: 508128XXXXXXXXXX)

E-Mail Address

Local Address

Phone

Do you use the New York State Telecommunications Relay Service to receive phone calls? Yes      No

OPTIONAL: Type of disability

Permanent
Temporary     Date Recovery Expected:

OPTIONAL:

Is there any information about you or your disability which you would like library staff to be aware of?

Please note: In order to document your eligibility for library services, a note will be placed in your library account information which is visible only to library staff. All information regarding library accounts is confidential.

Submitting this form indicates your agreement with the contents of this form.