Student Self-Disclosure Form

* indicates a required field

Student Information

Please enter your information
Please use your university issued email address
Which School are you enrolled in?Required
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

My diagnosed disability falls into the following category (please check all that apply)Required
ADHD
Alcohol or Substance Addiction Recovery
Autism Spectrum Disorder
Blind or Vision Impairment
Chronic Health Condition (Autoimmune disorders, Crohns, Diabetes, Cancer, Seizures, etc.)
Deaf or Hard of Hearing
Learning Disability (Reading, Writing, Math, Dyslexia etc.)
Mental Health (Depression, Anxiety, Bipolar, etc)
Mobility (Use of a wheelchair, crutches, braces etc.)
Motor (Cerebral palsy, Muscular dystrophy, Multiple sclerosis, Tourettes, etc)
Orthopedic (carpel tunnel, connective tissue disorders, Ehlers-Danlos Syndrome)
Other - Please describe below
Speech and Language Disorder (Stutter, Aphasia, etc.)
Temporary Disability (Expected duration of 6 months or less such as bone fractures, sprains, torn ligaments, post surgical recoveries, etc)
Traumatic Brain Injury or Concussion
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