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* Student's Name:
* Email:
* Street:
* City:
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If different from above, who is filling out the form?
Name:
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Phone:
Email:
Status:
Researching Schools In Application Process Admitted to NU
Anticipated semester/quarter of entry:
Fall Winter Spring Summer Summer 1 Summer 2
Are you a transfer student?
Yes No
Possible Major:
School/program you are interested in:
Freshman Sophomore Middler Junior Senior Other:
Major:
School/program:
Learning Disability
Attention Deficit Disorder
Deaf/Hard of Hearing
Blind or Visual Impairment
Physical or Mobility Impairment
Chronic or Degenerative Disorder
Psychological Disorder
Traumatic Brain Injury
Autism - Asperger's Syndrome or other
Temporary Disability
Other:
Please describe specific services and accommodations that you believe will help you to effectively function at Northeastern University.
Please add additional information or comments.
Disability Resource Center 360 Huntington Ave 20 Dodge Hall Boston, MA 02115
Phone:617-373-2675 TTY: 617-373-2730 Fax: 617-373-7800
