Application for Accessibility Services If you need assistance completing this form, please do not hesitate to call: 218.766.2139 NTC Accessibility Services Application Step 1 of 2 50% Date MM slash DD slash YYYY Name* First Middle Last Email* Phone*Local or Permanent Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Preferred course delivery method* On-Campus Online Combined Area of Study/Major* What services are you seeking by applying to Accessibility Services?*How does your condition lead to barriers in your classwork?*How does your condition lead to barriers with tests, quizzes and/or exams?*Describe what strategies or accommodations you've had in the past that have worked and how they mitigated the impact of your disability.*Are there any other areas where you find accessing the buildings, courses, materials, events, and/or activities challenging?*If you had to categories your disability or disabilities, please check all the boxes that apply:* Deaf/Lowered Hearing Blind/Low Vision Speech Impairment Motor (body movement) Impairment Mental Health Impairment Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder Specific Learning Disability Chemical Dependency Autism Spectrum Disorder Aspergerger's Syndrom Traumatic Brain Injury Systemic Disability Chronic Migraines Seizure Disorder Chronic Pain Other If Other, please describe Have you used or do you currently use any assistive technology? Yes No If yes, please list what tools, programs, or apps you have found helpful. In High School, were you enrolled in a Special Education Program? Yes No According tot he Americans with Disabilities Act, a disability is defined to be a physical or mental impairment that substantially limits one or more major life activities. Pelase indicate, from the following list, which major life activities are substantially limited by your disability.* Breathing Sleeping Seeing Hearing Caring for yourself Ingesting (Eating and/or Drinking) Thinking Concentrating Learning Reading Speaking Writing Sitting Reaching Interacting with others Manipulating (Using your hands with efficacy) Standing Walking Bending Lifting Other If Other, please describe If you are working with another agency to help support your education please list them here:Examples include: Vocational Rehabilitation, Veteran's Affairs, Social Services. Release of Information:If you would like Accessibility Services to be able to speak to anyone outside of the NTC community about your records and information with our office, please list them below.NameRelationshipContact Information To help you from a more holistic perspective, please evaluate yourself in the following academic areas.Please rate your skills as being Strong, Good, OK, Fair or Weak.ReadingStrongGoodOKFairWeakWritingStrongGoodOKFairWeakMathematicsStrongGoodOKFairWeakSpellingStrongGoodOKFairWeakOrganizationStrongGoodOKFairWeakTime ManagementStrongGoodOKFairWeakTaking InitiativeStrongGoodOKFairWeakResponsibilityStrongGoodOKFairWeakStudy SkillsStrongGoodOKFairWeakSelf AdvocacyStrongGoodOKFairWeakAssertivenessStrongGoodOKFairWeakManagement of Medication (if applicable)StrongGoodOKFairWeakManaging your disabilityStrongGoodOKFairWeakMotivationStrongGoodOKFairWeakInterpersonal RelationsStrongGoodOKFairWeakHealthy DietStrongGoodOKFairWeakRegular ExcerciseStrongGoodOKFairWeakSleep HabitsStrongGoodOKFairWeakPunctualityStrongGoodOKFairWeakAdjustment to ChangeStrongGoodOKFairWeakAccepting CriticismStrongGoodOKFairWeakCompletion of Tasks on TimeStrongGoodOKFairWeakFollowing DirectionsStrongGoodOKFairWeakPlease use the space below to describe any other concerns you may have that have not been addressed yet.