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Accessibility Services Application Form

* indicates a required field

Student Information

Welcome to Accessibility Services at Langara College! Please complete and submit the information below. We will contact you to book an intake appointment. If you have already booked an intake, please complete and submit this form prior to your appointment.

First NameRequired *

Last NameRequired *

Middle Name

Preferred Name

Student IDRequired *

EmailRequired *

Please use your college issued email address if you have one.

Phone NumberRequired *

Please enter your phone number in the following format: 555.123.4567

Can we leave you a confidential message at this number?

Can we leave you a confidential message at this number? Yes Can we leave you a confidential message at this number? No

Gender Pronoun

Other Gender Pronoun

Are you a student currently registered in courses?Required *

Are you a student currently registered in courses? Yes Are you a student currently registered in courses? No

If no, when is your starting semester?Required *

Nature of DisabilityRequired *

Chronic Health Disability
Cognitive
Hearing Disability
Mental Health Disability
Physical Disability
Neurological Disability (includes ADD/ ADHD, Learning Disabilities)
Visual Impairment
Not Sure/Unknown

Functional Limitations

Please describe any anticipated functional limitations you may experience in an academic setting.

Upload Documentation

If you already have documentation pertaining to your disability, upload it here or bring it to your intake appointment.

Document Information

Document TitleRequired *

FileRequired *

Maximum file size: 10240kb

Description