Accessibility Intake and Consent for Services

* indicates a required field

Student Information

This form is to be completed by any student who is NEW to Ambrose Accessibility Services.
Please use your university issued email address

Academic Information

Have you applied for financial aid?

Disability/Limitation Information

e.g. Anxiety, ADHD, Concussion, Cerebral Palsy, etc.
Have you been provided with accommodations or other support services in high school or at another post-secondary institution?
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Consent for Service

Consent StatementsRequired
  1. I give my consent for Ambrose Accessibility Services to view, and store, medical documentation that pertains to my access to accommodations.
  2. I understand that all information in my file is confidential, however, limits to confidentiality include three exceptions: (1) if you or another person is at risk of serious harm; (2) if you admit to child abuse or child neglect; or (3) if your information is subpoenaed in a court of law.
  3. I understand that the details of my Accessibility and Support Services Registration/Consent for Services, including supporting documentation, shall be treated as strictly confidential and shall not be disclosed to other persons without my consent except and to the extent that such disclosure is reasonably necessary for the effective implementation of my Accommodation Support Plan.
  4. If a support person has been designated, I consent to Accessibility Services including this person in discussions about my accommodations and the support provided through this office. Accessibility Services will not take direction from the support person, all student responsibilities still rest with me and decisions regarding my accommodations need to be made by me.
  5. I understand that academic accommodations are offered one semester at a time - if I require ongoing support services from Accessibility Services it is my responsibility to contact the Accessibility Office each semester to reactivate my Accessibility registration.
  6. I understand that my registration with Accessibility Services is necessary in order to access accommodations and/or supportive services. I may decide to discontinue my registration at any time.

Permission to Speak to:

If you are 18 years or older you have the option of designating a support person who can be included in discussions with the Accessibility Office as needed.
e.g. parent, guardian, spouse, etc.
Confidentiality and Retention of Documentation:

All information and documentation shared with the Accessibility Services Office will remain confidential to the staff associated with the office and will not become a part of the student's permanent record. Documents will be stored securely for a period of 7 years after which documentation will be destroyed.