Student Self-Disclosure Form

* indicates a required field

Student Information

Please enter your information
Please use your university issued email address
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Are you in the Binghamton Advantage Program (BAP)?Required
Are you in the Baccalaureate Accelerated Track (BAT) ProgramRequired
Do you need assistance in an emergency evacuation?Required

Specific Disability Information

Upload supporting document(s) (e.g. Psycho-Ed Evaluation, Neuropsych Evaluation, Provider Forms)

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