Register with ARC

Last Name:      First Name:      Middle Initial:   

CSUC ID #:   

Date of Birth:   

Preferred Phone #:

E-mail

May we leave a detailed message disclosing that we are calling from the ARC?   Yes    No

Please check all that apply
Continuing Chico State Student
First Semester Freshman (currently or in upcoming semester),   When?:
First Semester Transfer (currently or in upcoming semester),   From What College?:
Enrolled in Open University
Registered with Educational Opportunity Program (EOP)
Receive Financial Aid
English as a Second Language
A Military Veteran
Client of Department of Rehabilitation,   Counselor's name and office:

Chico State Major:    Class Level:

Note: Documentation of your disability is required in order to receive services. Please submit disability documentation with this application form. See guidelines for documentation of specific disability categories listed on the ARC website

Please check all that apply
Blind or Low Vision
Service Dog User
Attention Deficit/Hyperactivity Disorder (AD/HD)
Communication Disability
Psychological or Psychiatric Disability
Deaf or Hard of Hearing
Chronic Health Condition/ Other Functional limitations,   Please Specify:
Learning Disability
Acquired Brain Injury
Mobility Disability

Services are individualized based on functional limitations and requirements of the specific course/instruction. Services are subject to approval by Accessibility Resource Center.

Please check services you are interested in learning about or that you would like to request using at Chico State.
Priority Registration
Instructional Materials in Alternate Format
Specialized Furniture
Cart Services
Accessible Parking
In Class Educational Assistant
Audio Recording of Lectures
Other Services or Issues,   Please Specify:
Exam Services,   Please Specify:
Assistive Technology,   Please Specify:
Sign Language Interpreter Services
Real Time Captioning Services
Scribe
Note Taker
Referral to Assistive Technology Center (ATC)

Please read, sign and date the following confidentiality and disclosure statement:

I understand that disability related information I provide to Accessibility Resource Center at Chico State is confidential and can only be disclosed at my request except when:

1. The ARC staff advises university faculty and staff on how to implement a reasonable accommodation I have requested and that I am eligible to use.
2. The ARC staff consults with university faculty and staff, on a need to know basis, in the event a health and safety issue occurs.
3. I have received a copy of ARC Student Rights, Responsibilities & Dispute Resolution.
4. I have been informed of Emergency Preparedness for persons with disabilities.

Typing your name below is valid as a written signature.

Student Name (type):    Date: