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Student Self-Disclosure Form
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Student Information
Please enter your information
First Name
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*
Last Name
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Preferred name
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Pronouns
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*
Date of Birth (MM/DD/YY)
B-Number
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*
Binghamton University Email
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Please use your university issued email address
Phone Number
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Which School are you enrolled in?
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Harpur School of Arts and Sciences
Decker College of Nursing and Health Sciences
School of Pharmacy and Pharmaceutical Sciences
School of Management (SOM)
Watson School Engineering
College of Community and Public Affairs (CCPA)
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Student Status
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Undergraduate Student
Graduate Student
Transfer Student - Undergraduate
Transfer Student - Graduate
Summer Only
Winter Only
Are you in the Baccalaureate Accelerated Track (BAT) Program
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*
Are you in the Baccalaureate Accelerated Track (BAT) Program
Yes
Are you in the Baccalaureate Accelerated Track (BAT) Program
No
Specific Disability Information
My diagnosed disability falls into the following category (please check all that apply)
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If unsure, please describe
How does your disability affect you academically (e.g., studying, reading, note-taking, test taking)?
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How does your disability impact your day to day functioning (e.g., eating, sleeping, physical mobility)?
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Upload supporting document(s) (e.g. Psycho-Ed Evaluation, Neuropsych Evaluation, Provider Forms)
Please refer to https://www.binghamton.edu/ssd/prospective-students/documentation-requirements.html
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Document Information
Document Title
File
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Maximum file size: 10240kb
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