Student Information Form

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1700 Spring Garden Street | Philadelphia, PA 19130
Bonnell Building, Ground Floor, Room 39 (BG-39)
phone: 215-751-8050 | email: | website:

Please use your college issued email address (example:
Did you enter your CCP email address, ending in in the box above?Required

Disability/Accommodation Information

Requested Accommodations
Do you require assistance during emergencies that require building evacuation?
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Affirmation StatementRequired

I affirm that the information I am uploading accurately reflects the nature of my current condition and that the person who prepared the information is a professional qualified to provide such information. Additionally, I authorize the Center on Disability to contact the professional(s) who have prepared my documentation to request clarification in considering my accommodation request(s).

I understand that any information I provide to the Center on Disability is considered an educational record protected by the Family Educational Rights and Privacy Act ("FERPA"). FERPA permits the Center on Disability to share information about the impact of a disability and accommodation eligibility with other school officials who have a legitimate educational interest, including faculty and administrators who are working in the educational interests of the student. Subject to certain exceptions, FERPA generally prevents disclosure of educational records without my consent to third parties that are not considered school officials. By checking this box I authorize the Center on Disability to disclose my education records to the medical professional(s) and/or practice(s) who have prepared my documentation to the extent necessary to consider my accommodation request.

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