Application for Services

Louisiana Delta Community College
Office of Student Counseling and Disability Services

Name Name First Last
Campus
Mailing Address Mailing Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Email
Campus ID (L#)
Must be 8 digits. Currently Entered: 0 digits.
Enter only the 8 digits
Disability
Date of Birth Date of Birth / MM / DD YYYY
Are you registered with Louisiana Rehabilition Services (LRS)?

Are you registered with Louisiana Rehabilition Services (LRS)? Yes No Other Other
How does your disability impact you, as a student?
What accommodations are you requesting or have you used in the past?
I understand that I am not officially registered with Student Counseling and Disability Services until I have talked with a counselor and the accommodations have been approved.

I understand that I am not officially registered with Student Counseling and Disability Services until I have talked with a counselor and the accommodations have been approved. Yes
I acknowledge that the Office of Student and Disability Services Student Handbook is available to me online. I understand that it is my responsibility to adhere to the procedures as outline in the Handbook.

I acknowledge that the Office of Student and Disability Services Student Handbook is available to me online. I understand that it is my responsibility to adhere to the procedures as outline in the Handbook. Yes
Type your name in the box below.
I understand this is a legal representation of my signature.