University of Hawaii at Hilo
University Disability Services
200 West Kawili St.
Hilo, HI 96720
This form is available in alternate format upon request by contacting the University Disability Services.
1. Name________________________________ 2. SS#_________________________
3. Local Address (Street/box no. city state zip)
_________________________________________________________
4. Telephone Numbers: Residence________________Work______________________
5. E-mail address______________________________
6. Permanent Home Address________________________________________________
street/box no. city state zip
7. Date of birth________________ 8. Place of birth_____________________________
9. Sex: M__F__ 10. Marital Status________ 11. No. of Children___under 18________
12. Citizenship: U.S.____Permanent Resident____FSM____Marshall
Island___________
13. Ethnic Background (This is optional, but it will assist us in identifying
scholarships or other
Programs you may be eligible for).
______________________________________________________________________
14. What is your first language? (e.g. ASL, English)_______________________________
15. List any post-secondary institutions attended (other than UH Hilo),
if any, and the high school from which you graduated:
Dates Institution Location Attended Major Degree _______________ _____________ _____________ ________ _______ _______________ _____________ _____________ ________ _______ _______________ _____________ _____________ ________ _______ _______________ _____________ _____________ ________ _______
Return to Room 311, Campus Center Building
Or mail to: UDS UH Hilo, 200 W. Kawili St., Hilo, HI 96720-4091
16. Current Class Standing: Freshman____ Sophomore____ Junior____ Senior____
Unclassified____
17. New____ Continuing____ Transfer____ Returning(after a break)____
18. Major(s):____________________________________ Minor(s):________________
19. Full-time or Part-time____________ Traditional or Non-traditional______________
20. Name of Academic Advisor (if known)_____________________________________
21. Veteran ____Yes ____No If yes, are you receiving Veterans Chapter
31/Voc. Rehab.
Services? ____Yes ____No
22. Disability verification:
(a) Do you have a disability?
____No. If no, please go to the next page.
____Yes. If yes, check the appropriate box(es):
Hearing____Mobility____Visual____Orthopedic____Learning____
Other (specify)___________________________________________
(b) Were you in a resource classroom in high school or elementary school?__Yes
__No
(c) Are you requesting accommodations for the disability? ___Yes ____No
(d) The above disability has been documented by______________________
On______________. Please attach a copy of documentation.
PERSONAL STATEMENT
1. What has been the most outstanding accomplishment in
your life?
2. What are your goals in life?
3. How can UDS assist you?
I hereby certify that the information provided is true to the best of
my knowledge.
___________________________________ _______________________
Signature and Date