Application for Disability Support Services

Student Information

Please enter your information

First Name

Last Name

Middle Initial

Preferred Name

Student ID

If a current Gateway student, please enter your ID number.
If a prospective student, please enter in ***birthdate (example: ***09012000).

Email

If a current Gateway student, please use your college issued email address.
If a prospective student, please use your personal email address.

Phone number where you can be reached

If 'Other' is chosen, please specify location.

I am requesting accommodations for

If 'Other" is chosen, please specify.

Name of High School

Case Manager Name and Title

Case Manager Email

Case Manager Phone

Describe how your disability impacts your learning.

Accommodations and/or support services that have helped you overcome barriers.

Upload supporting document(s)

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