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