Online Student Application

1. Start Term *: Select One 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall
   Note: Select when you would like to start your services.
2. Expected Graduation Term: Select One 2001 - Spring 2001 - Fall 2002 - Spring 2002 - Fall 2003 - Spring 2003 - Fall 2004 - Spring 2004 - Fall 2005 - Spring 2005 - Fall 2006 - Spring 2006 - Fall 2007 - Spring 2007 - Fall 2008 - Spring 2008 - Fall 2009 - Spring 2009 - Fall 2010 - Spring 2010 - Fall 2011 - Spring 2011 - Fall 2012 - Spring 2012 - Fall 2013 - Spring 2013 - Fall 2014 - Spring 2014 - Fall 2015 - Spring 2015 - Fall 2016 - Spring 2016 - Summer 2016 - Fall 2017 - Spring 2017 - Summer 2017 - Fall 2018 - Spring 2018 - Summer 2018 - Fall 2019 - Spring 2019 - Summer 2019 - Fall 2020 - Spring 2020 - Summer 2020 - Fall 2021 - Spring 2021 - Summer 2021 - Fall 2022 - Spring 2022 - Summer 2022 - Fall 2023 - Spring 2023 - Summer 2023 - Fall 2024 - Spring 2024 - Summer 2024 - Fall 2025 - Spring 2025 - Summer 2025 - Fall 2026 - Spring 2026 - Summer 2026 - Fall 2027 - Spring 2027 - Summer 2027 - Fall 2028 - Spring 2028 - Summer 2028 - Fall 2029 - Spring 2029 - Summer 2029 - Fall 2030 - Spring 2030 - Summer 2030 - Fall 2031 - Spring 2031 - Summer 2031 - Fall 2032 - Spring 2032 - Summer 2032 - Fall 2033 - Spring 2033 - Summer 2033 - Fall
   Note: Select when you plan to graduate.
3. First Name *:
4. Last Name *:
5. Middle Name:
6. Optional: Preferred Name:
7. Student ID:
   Hint: Enter 7 alpha numeric characters.
8. Birth Date:
   Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
9. Gender *: Select One Female Male Nonbinary Not Specified
10. Pronouns: Select One Any pronouns He/him/his He/him/his, They/them/theirs Just my name please (no pronouns) She/her/hers She/her/hers/, They/them/theirs They/them/theirs Ze/hir/hirs

1. Primary Phone Number:
   Hint: Enter 10-digit number only.
2. Secondary Phone Number:
   Hint: Enter 10-digit number only.
3. Email Address *:

1. Address *:
2. City *:
3. State *: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode *:
   Hint: Enter zipcode as 97331 or 97331-0000.

Same as Local Address

1. Address:
2. City:
3. State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Wyoming International
4. Zipcode:
   Hint: Enter zipcode as 97331 or 97331-0000.

1. Primary Disability *: Select One === General Category === ADD/ADHD - attention deficit disorder, attention deficit/hyperactivity disorder CMC - chronic medical condition ED - eating disorder HD - hearing disability, hearing loss LD - learning disability MD - mobility disability Other PD - psychological/psychiatric disability SA - substance abuse/recovery TBI - traumatic brain injury Temporary condition - please specify below VI - visual disability/blindness/low vision
2. Secondary Disability(ies)

   General Category

   ADD/ADHD - attention deficit disorder, attention deficit/hyperactivity disorder

   CMC - chronic medical condition

   ED - eating disorder

   HD - hearing disability, hearing loss

   LD - learning disability

   MD - mobility disability

   Other

   PD - psychological/psychiatric disability

   SA - substance abuse/recovery

   TBI - traumatic brain injury

   Temporary condition - please specify below

   VI - visual disability/blindness/low vision
3. Other Disability or Note:
4. Seeking Degree: Select One Master Degree Ph.D. Degree Post Baccalaureate Undergraduate

Affiliation(s)

5. Affiliation(s)

   Commission for the Blind

   Distance Education

   Division of Vocational Rehabilitation

   EOP/SSS

   Veterans

   Youth Transition Program

Ethnicity(ies)

6. Ethnicity(ies)

   African-American

   Asian or Pacific Islander

   Caucasian

   European-American

   Hispanic

   Multi-Racial

   Native American

   Prefer not to identify

Campus Location(s)

7. Campus Location(s)

   Barnard CARDS Office - 101 Altschul

   Barnard CARDS Testing Center - Barnard Hall 101
8. Additional Note:

1.  

   What is your current student status and class year?

   Transfer

   Readmitted

   International

   Visiting

   Post-Bac

   First Year

   Sophomore

   Junior

   Senior

   Additional Note or Comment
2. Who were you referred by? * (Required)
3.  

   Have you already scheduled or completed your intake meeting? Please note that our office follows a case manager model. Your intake should be completed with the case manager for your anticipated graduation year. * (Selection is Required)

   Yes, I have scheduled my intake meeting.

   No, I have not yet scheduled my intake meeting.

   Additional Note or Comment
4.  

   Do you want to identify a parent/guardian that we may contact in case of emergency? If so, please indicate name and phone number. * (Selection is Required)

   Yes

   No

   I will contact CARDS later to identify a family contact.

   Additional Note or Comment
5. When were you first diagnosed with your disability/ condition(s)? * (Required)
6. Current treating clinician & contact information: * (Required)
7. Are you currently taking any medications related to your disability/condition(s)? If so, please list below. * (Required)
8.  

   Have you ever had an IEP or Section 504 plan or received accommodations in high school? * (Selection is Required)

   IEP (Individualized Education Plan)

   Section 504

   Received accommodations without an IEP or 504 plan

   No

   I'm not sure

   Additional Note or Comment
9. Please list any previous accommodations you have received: * (Required)
10. Do you have a temporary injury that impacts you academically (i.e. concussion, broken wrist)? If so, please specify below along with the approximate date of the injury. * (Required)
11. Have you consulted with Barnard Primary Care Health Services for your condition(s)? If so, when? * (Required)
12. Please describe how your condition/disability impacts you academically (i.e. reading, writing, concentration, memory, time management): * (Required)
13. If you are applying for Disability-related Housing Accommodations (which is a separate application process), please describe how your condition/disability impacts you in your living situation: * (Required)
14.  

    Do you require modifications to physical activity and/or special placement in your Physical Education class? (Please note that this must be arranged before the start of the semester in consultation with CARDS and the Physical Education Department Chair.) * (Selection is Required)

    Yes (Specify Below)

    No (Specify Below)

    Additional Note or Comment
15. Do you currently use any assistive technology (i.e. Dragon Naturally Speaking, JAWS, Read out Loud, etc.)? If so, please specify: * (Required)
16.  

    Do you need assistance evacuating a campus building in case of an emergency? * (Selection is Required)

    Yes (if so, please fill out our Disability Evacuation Assistance Registration Form):

    No

    Additional Note or Comment