Application for Services - Self Report

Broward College students requesting accommodations must self-identify, submit qualifying documentation, and complete this application prior to meeting with the campus coordinator. Completion of this form does not guarantee services. We will contact you for an interview.

* indicates a required field

Student Information

Student ID Number

First Name

Last Name

Middle Name

Broward College Email Address

Cell Phone Number

Emergency Contact Name

Emergency Contact

Relationship

Emergency Contact Cell Number

Which campus do you primarily attend classes?

Specific Accommodation Information

What is your disability or disabilities?

Based on your disability, which academic accommodations are you requesting?

If you are requesting classroom accommodations, please explain why you feel these are needed.

If you are requesting testing accommodations, please explain why you feel these are needed.

What is your major/career pathway?

Voter Registration Information

During your initial interview, a coordinator will provide the documents to register to vote or update your voter registration based on your selection below.

If you are not registered to vote where you live now, would you like to apply to register to vote today?

If you are registered to vote where you live now, would you like to update your voter registration record?

Upload supporting document(s)

Please provide documentation for each disability requiring accommodations. Click here to access documentation guidelines and verification forms.

Application for Services - Self Report

Student Information

Specific Accommodation Information

Document Information