Disability Services & Access (DSA) Form

"*" indicates required fields

A. Student Information

DD slash MM slash YYYY
Fill in only if applicable!
Fill in only if applicable!
Current Address:*
Home Address:*

B. Academic Information

Course Attending:*

C. Previous School(s) & Accommodation(s)

D. Disability Information

Select one or more disabilities:

IV. Only complete the sections below that apply to your documented disability/ies, then proceed to section VI.

Part 1 - Learning disability, AD/HD, Traumatic Brain Injury and Psychological Disabilities Mobility Disabilities

Part 2 - Deaf or Hard of Hearing

Part 3 - Chronic Medical Condition and physical or other mobility disabilities

Part 4 - Visual Disability or Blind

Part 1

Part 2

Do you wear hearing aids or cochlear impants?
If Yes, Select the one that apply:
Do they have Direct Audio Input (DAI)?
Please choose your preferred method of communication:
What means of expression and receptive communication do you use?
Tick the ones that apply to you.

Part 3

Please, choose the ones that apply:
Please specify!
Do you experience any of the following?
Please describe:

Part 4:

Visual Activity (If Applicable)
Degree of Blindness:
Mobility Aids:
Do you use alternate format reading materials?

V. Disability Documentation

Please provide information about the disability documentation you will be submitting to our office. Note that you are responsible to ensure that your documentation meets the Kasa High School Regulations.
DD slash MM slash YYYY
Type of Documentation:

VI. Accommodation & Services

Please specify what accommodations you request. Disability services will consider your request in light of your disability as described in your supporting documentation and other information provided to disability services, as well as the requirements of your course.
Testing Accommodation:
Classroom Accommodation:
Communication/Technology Accommodation:
Please tick the appropriate box: