Application For DRES Services

Dear Prospective Student:  

Thank you for your interest in services for students with disabilities offered by DRES.  It is important that you complete and return this application with supporting disability documentation as soon as you are admitted to the university or are aware of a disability-related need for services.  Such information will help us work with you to plan effective academic adjustments, auxiliary aids, or services during your tenure as a student at Illinois.  Refer to the DRES document entitled Documentation Requirements for specific documentation requirements for your disability.  Please note that services cannot begin until a completed application (application and disability documentation) is on file in the DRES Student Services Office.

I. Background Information

University of Illinois Enrollment

Race/Ethnicity (optional for statistical purposes)

II. Academic History

High Schools Attended

Colleges / Universities Attended

III. General Nature of Disability/Disabilities

Include diagnosis as well as cause and date of onset.

IV. Use of Assistive Technology, Document Conversion, or Captioning

V. Disability-Specific Information

Primary or Secondary Vision Disabilities

To be completed only by individuals with primary or secondary vision disabilities.

Previous Mobility Training:

Primary or Secondary Hearing Disabilities

To be completed only by individuals with primary or secondary hearing disabilities.

Disabilities Affecting Mobility

To be completed only by individuals with disabilities affecting mobility.

VI. DRES Release of Disability Related Information

I, the undersigned, understand that in order for the Division of Disability Resources and Educational Services (DRES) to verify my disability, as well as the functional manifestations of my disability for which academic adjustments, auxiliary aids and/or other accommodative services may be required, DRES must obtain pertinent student evaluations, psychological reports, transcripts, and medical reports. I understand that to obtain these reports this form must be signed and on file in the DRES Student Services Office.

I understand that no one other than DRES personnel has immediate access to my DRES files, and that any information regarding my disability which is gained from these files shall be considered confidential and will only be shared with others within the institution on a need-to-know basis. I further understand that my reports will not be released by DRES except in accordance with federal and state laws.

Therefore, for the purposes noted above and in accordance with the conditions specified, I hereby authorize release of information from my reports to authorized personnel at the University of Illinois and the Division of Disability Resources and Educational Services.

Typing your name below indicates authorization to release this information.

Parent/Guardian if student is under 18 years of age:

Typing your name below indicates authorization to release this information.

Please also send required documentation materials to:

Student Services Office
Division of Disability Resources and Educational Services
1207 S. Oak Street
Champaign, IL 61820

Revised 1/11