Request for Services

Accessibility & Disability Services
Assiniboine College
1035 1st Street North MICA
Room 236
Brandon, Manitoba R7A 2Y1
725.8700 ext 6052 | Toll free 800.862.6307
[email protected]

*Required fields

First and Last Name:

Pronouns:

She/Her

He/Him

They/Them

Prefer not to answer

Phone Number:

Email:

Student Status:

Future Student: not yet admitted to Assiniboine

New Student: first year on campus

Continuing Student but new to Accessibility and Disability Services

Other…

Assiniboine Student ID Number (If applicable):

Program:

At any time, have you received accommodations?

Yes

List past accommodations, if applicable:

Do you require accommodations for a meeting with us?

Do you have documentation verifying your disability and recommending accommodations?

If yes, please bring your documentation to your first meeting. If no, please arrange to get your documentation to your first meeting by contacting [email protected]

Yes

How is your education being funded?

Self-funded

Manitoba Student Aid

Sponsorship from an agency or foundation (ex. CNIB)

Other…

Is there anything else you would like Accessibility & Disability Services to know prior to your first meeting?

Privacy Statement Declaration

I declare that I have read and understood the information in the Privacy Statement For Applicants And Students. By submitting your Request for services, you confirm that you consent to the collection and use of your personal information as set out in that statement.