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Access Form
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This application is for students that do not have disability accommodations at Bellevue College, and would like to discuss them. Check out our
Getting Started with the DRC
page for more information about our accommodations process or
contact us
!
Email Confirmation: When this form is submitted successfully you will receive an email confirmation at your
Bellevue College email address
. If you do not receive a confirmation email, please
email us
to let us know!
Personal Information
Start Term
*
:
Select One
2023 - Fall
2024 - Winter
2024 - Spring
2024 - Summer
2024 - Fall
2025 - Winter
2025 - Spring
2025 - Summer
2025 - Fall
2026 - Winter
2026 - Spring
2026 - Summer
2026 - Fall
2027 - Winter
2027 - Spring
2027 - Summer
2027 - Fall
2028 - Winter
2028 - Spring
2028 - Summer
2028 - Fall
2029 - Winter
2029 - Spring
2029 - Summer
2029 - Fall
2030 - Winter
2030 - Spring
2030 - Summer
2030 - Fall
2031 - Winter
2031 - Spring
2031 - Summer
2031 - Fall
2032 - Winter
2032 - Spring
2032 - Summer
2032 - Fall
2033 - Winter
2033 - Spring
2033 - Summer
2033 - Fall
2034 - Winter
2034 - Spring
2034 - Summer
2034 - Fall
2035 - Winter
2035 - Spring
2035 - Summer
2035 - Fall
2036 - Winter
2036 - Spring
2036 - Summer
2036 - Fall
2037 - Winter
2037 - Spring
2037 - Summer
2037 - Fall
2038 - Winter
2038 - Spring
2038 - Summer
2038 - Fall
2039 - Winter
2039 - Spring
2039 - Summer
2039 - Fall
2040 - Winter
2040 - Spring
Note: Select when you would like to start your services.
Expected Graduation Term:
Select One
Pre 2010
2010 - Summer
2010 - Fall
2011 - Winter
2011 - Spring
2011 - Summer
2011 - Fall
2012 - Winter
2012 - Spring
2012 - Summer
2012 - Fall
2013 - Winter
2013 - Spring
2013 - Summer
2013 - Fall
2014 - Winter
2014 - Spring
2014 - Summer
2014 - Fall
2015 - Winter
2015 - Spring
2015 - Summer
2015 - Fall
2016 - Winter
2016 - Spring
2016 - Summer
2016 - Fall
2017 - Winter
2017 - Spring
2017 - Summer
2017 - Fall
2018 - Winter
2018 - Spring
2018 - Summer
2018 - Fall
2019 - Winter
2019 - Spring
2019 - Summer
2019 - Fall
2020 - Winter
2020 - Spring
2020 - Summer
2020 - Fall
2021 - Winter
2021 - Spring
2021 - Summer
2021 - Fall
2022 - Winter
2022 - Spring
2022 - Summer
2022 - Fall
2023 - Winter
2023 - Spring
2023 - Summer
2023 - Fall
2024 - Winter
2024 - Spring
2024 - Summer
2024 - Fall
2025 - Winter
2025 - Spring
2025 - Summer
2025 - Fall
2026 - Winter
2026 - Spring
2026 - Summer
2026 - Fall
2027 - Winter
2027 - Spring
2027 - Summer
2027 - Fall
2028 - Winter
2028 - Spring
2028 - Summer
2028 - Fall
2029 - Winter
2029 - Spring
2029 - Summer
2029 - Fall
2030 - Winter
2030 - Spring
2030 - Summer
2030 - Fall
2031 - Winter
2031 - Spring
2031 - Summer
2031 - Fall
2032 - Winter
2032 - Spring
2032 - Summer
2032 - Fall
2033 - Winter
2033 - Spring
2033 - Summer
2033 - Fall
2034 - Winter
2034 - Spring
2034 - Summer
2034 - Fall
2035 - Winter
2035 - Spring
2035 - Summer
2035 - Fall
2036 - Winter
2036 - Spring
2036 - Summer
2036 - Fall
2037 - Winter
2037 - Spring
2037 - Summer
2037 - Fall
2038 - Winter
2038 - Spring
2038 - Summer
2038 - Fall
2039 - Winter
2039 - Spring
2039 - Summer
2039 - Fall
2040 - Winter
2040 - Spring
Note: Select when you plan to graduate.
First Name
*
:
NOTE: Please enter the first name you most commonly use, would like to appear on all correspondence from the DRC, and/or want to be referred to as.
Last Name
*
:
Middle Name:
Student ID
*
:
Hint: Enter 9 alpha numeric characters.
Birth Date
*
:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Gender
*
:
Select One
Androgynous
Femme
Gender Neutral
Gender Non-Conforming
Gender other than what is listed here
Genderfluid
Genderqueer
Man
Masc
Non-Binary
Not Specified
Prefer not to answer
Trans Feminine
Trans Man
Trans Masculine
Trans Woman
Transgender
Woman
Pronouns:
Select One
ae, aer, aers
any
co, cos
ey, em, eirs
he, him, his
he/his & they/them
it, its
name only (no pronouns)
Not Specified
nounpronouns (fae, faer / bun, buns)
per, pers
pronouns other than what is listed here
she, her, hers
she/hers & they/them
they, them, their
they/them & he/his
they/them & she/hers
ve, ver, vis
xe, xim, xis
ze, zir, zirs
zie, hir, hirs
zy, zy, zys
Contact Information
Primary Phone Number:
Hint: Enter 10-digit number only.
Secondary Phone Number:
Hint: Enter 10-digit number only.
Email Address
*
:
Hint: Please enter your Bellevue College email address (@bellevuecollege.edu)
Local Address
Address
*
:
City
*
:
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
Zipcode
*
:
Hint: Enter zipcode as 97331 or 97331-0000.
Permanent Address
Same as Local Address
Address:
City:
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
Zipcode:
Hint: Enter zipcode as 97331 or 97331-0000.
Additional Information
Primary Disability
*
:
Select One
=== General Category ===
ADD/ADHD (4G)
Allergies (6N)
Anxiety (8R)
Asthma (6L)
Auditory Processing Disorder (4H)
Autism Spectrum (8S)
Autoimmune Disease (6N)
Bipolar (8R)
Blind (5I)
Borderline Personality Disorder (8R)
Brain Injury-Acquired (7P)
Brain Injury-Traumatic (7P)
Cancer (6K)
Cardiovascular/Pulmonary (6L)
Celiac Disease (6N)
Cerebral Palsy (7O)
Cognitive Disability, may be identified or 'Not Otherwise Specified' (4H)
COVID19/Coronavirus (TBD)
Deaf (1A)
Depression (8R)
Developmental Disability (7Q)
Diabetes (6N)
Dyscalculia (4H)
Dysgraphia (4H)
Dyslexia (4H)
Eating Disorder (8R)
Epilepsy (7O)
Fibromyalgia (6N)
Fragrance/Chemical Sensitivity (6N)
Gastrointestinal, Immune (6N)
Hard of Hearing (1B)
Learning Disability, may be identified or 'Not Otherwise Specified' (4H)
Limited Gait or Range of Motion (2C)
Math Disability (4H)
Migraines (7O)
Motor Neuron (7O)
Narcolepsy (7O)
Non-Specified Mental Health Condition (8R)
Obsessive Compulsive Disorder (8R)
Oral Expression (4H)
Organ, Blood, Tissue (6N)
Orthopedic Conditions, Acute (6M)
Orthopedic Conditions, Chronic (6M)
Other
Paraplegic (2D)
Personality Disorder (8R)
Post-Acute Sequelae SARS-CoV-2 Infection (PASC or Long Covid)
Postural Orthostatic Tachycardia Syndrome (6N)
Pregnancy (not a disability)
Pregnancy Complications
PTSD (8R)
Quadriplegic (2E)
Reading Disability (4H)
Schizophrenia (8R)
Seizure (7O)
Sensory Processing Disorder (8S)
Speech or Language Disability (3F)
Thyriod Disorders (6N)
Tourette's Syndrome (7O)
Visual Impairment (5J)
Writing Disability (4H)
Secondary Disability(ies)
General Category
ADD/ADHD (4G)
Allergies (6N)
Anxiety (8R)
Asthma (6L)
Auditory Processing Disorder (4H)
Autism Spectrum (8S)
Autoimmune Disease (6N)
Bipolar (8R)
Blind (5I)
Borderline Personality Disorder (8R)
Brain Injury-Acquired (7P)
Brain Injury-Traumatic (7P)
Cancer (6K)
Cardiovascular/Pulmonary (6L)
Celiac Disease (6N)
Cerebral Palsy (7O)
Cognitive Disability, may be identified or 'Not Otherwise Specified' (4H)
COVID19/Coronavirus (TBD)
Deaf (1A)
Depression (8R)
Developmental Disability (7Q)
Diabetes (6N)
Dyscalculia (4H)
Dysgraphia (4H)
Dyslexia (4H)
Eating Disorder (8R)
Epilepsy (7O)
Fibromyalgia (6N)
Fragrance/Chemical Sensitivity (6N)
Gastrointestinal, Immune (6N)
Hard of Hearing (1B)
Learning Disability, may be identified or 'Not Otherwise Specified' (4H)
Limited Gait or Range of Motion (2C)
Math Disability (4H)
Migraines (7O)
Motor Neuron (7O)
Narcolepsy (7O)
Non-Specified Mental Health Condition (8R)
Obsessive Compulsive Disorder (8R)
Oral Expression (4H)
Organ, Blood, Tissue (6N)
Orthopedic Conditions, Acute (6M)
Orthopedic Conditions, Chronic (6M)
Other
Paraplegic (2D)
Personality Disorder (8R)
Post-Acute Sequelae SARS-CoV-2 Infection (PASC or Long Covid)
Postural Orthostatic Tachycardia Syndrome (6N)
Pregnancy (not a disability)
Pregnancy Complications
PTSD (8R)
Quadriplegic (2E)
Reading Disability (4H)
Schizophrenia (8R)
Seizure (7O)
Sensory Processing Disorder (8S)
Speech or Language Disability (3F)
Thyriod Disorders (6N)
Tourette's Syndrome (7O)
Visual Impairment (5J)
Writing Disability (4H)
Other Disability or Note:
Seeking Degree:
Select One
Associate
Baccalaureate
Certificate
GED
Personal Development
Running Start/High School
Major:
Select One
Applied Accounting
Applied Arts
Applied Sciences
Business Professions
Communications
Computers and Technology
Eastern @ BC
Education
General Studies
Health
Healthcare Technology and Management
Information Systems and Technology
Interior Design
Nuclear Medicine Technology
Nursing
Occupational and Life Skills
Online BA with UW or WSU
Public Safety
Radiation and Imaging Sciences
Running Start/High School
Transfer in Arts and Sciences
Transfer in Business
Transfer in Math Education
Transfer in Science
Affiliation(s)
Affiliation(s)
BC Financial Aid
Department of Services for the Blind (DSB)
Department of Vocational Rehabilitation (DVR)
Disabled Students Navigating STEM (DSNS)
Labor & Industries (L&I)
Neurodiversity Navigators
Public Assistance
Social Security including Disability Social Security
TRIO
Veteran's Assistance
Worker Retraining/Work First
Ethnicity(ies)
Ethnicity(ies)
Black, Afro-Caribbean, African or African American
East Asian or Asian American
Indigenous, Native American or Alaskan Native
Latino, Latina, Latine or Chican@
Middle Eastern or Arab American
Mixed Race
Native Hawaiian or Pacific Islander
Prefer not to answer
Race or Ethnicity other than what is listed here
South Asian or Indian American
White or European American
Additional Note:
Questions
Can we leave you detailed voicemails?
Yes, you can leave me detailed messages at the phone number (Specify Below)
No
Additional Note or Comment
Your Emergency Contact's Name
*
(Required)
Your Emergency Contact's Phone Number:
*
(Required)
We use self-report of a student's disability as our main source of information to determine accommodations. The following questions will allow us to collect some information about your disability barriers and will serve as self report of your disability. If any of these questions do not make sense to answer or are confusing, please feel free to skip them!
Okay
Additional Note or Comment
Self-Report: What is your disability or health conditions?
*
(Selection is Required)
I would like to answer (Specify Below)
N/A
Skip
Additional Note or Comment
Self-Report: How long have you experienced your disability or health conditions?
*
(Selection is Required)
I would like to answer (Specify Below)
N/A
Skip
Additional Note or Comment
Self-Report: How does your disability or health condition impact you?
*
(Selection is Required)
I would like to answer (Specify Below)
N/A
Skip
Additional Note or Comment
Self-Report: What barriers do you experience in your daily life (ex. Cannot walk a long distance, difficulty concentrating on reading material for a long period of time)?
*
(Selection is Required)
I would like to answer (Specify Below)
N/A
Skip
Additional Note or Comment
Self-Report: What barriers do you experience in school? If you have not been in school for some time what barriers do you think you might experience?
*
(Selection is Required)
I would like to answer (Specify Below)
N/A
Skip
Additional Note or Comment
Self-Report: What accommodations would help you have access to school?
*
(Selection is Required)
I would like to answer (Specify Below)
N/A
Skip
Additional Note or Comment
Self-Report: Did you have a 504 or IEP while in school?
*
(Selection is Required)
Yes
No
Skip
Additional Note or Comment
Do you need an interpreter? ¿Necesita un intérprete?
American Sign Language
Español
Another language (Specify Below)
Additional Note or Comment
If you are not registered to vote where you live now, would you like to register to vote now?
*
(Selection is Required)
Yes, I would like to register to vote online on my own at
https://www.usa.gov/register-to-vote
Yes, I would like to register to vote, but I need assistance filling out the forms
No, I would not like to register to vote
I am already registered to vote
Prefer not to answer
Additional Note or Comment
Identity-based questions are asked because we believe that students with disabilities are an integral part of diversity. This information is confidential and will only be used in anonymous data analysis. Let us know if you have any questions!
Okay
Additional Note or Comment
Optional Information: Sexual and Romantic Orientation
Aromantic
Asexual
Biromantic
Bisexual
Demiromantic
Demisexual
Gay
Heteromantic
Homoromantic
Lesbian
Panromantic
Pansexual
Polyamorous
Queer
Questioning
Straight/Heterosexual
Prefer not to answer
Sexuality other than what is listed here (Specify Below)
Additional Note or Comment
Optional Information: Have you served in the military?
Yes, US Active duty military
Yes, US Reserves
Yes, previous US military veteran
Yes, military service outside of the US
No, I have not
Prefer not to answer
Additional Note or Comment
Optional Information: Religion/Spirituality
Agnostic
Atheist
Buddhist
Catholic
Christian
Hindu
Jewish
Muslim
Omnist
Pagan
Sikh
Spiritual
Wiccan
Religion other than what is listed here (Specify Below)
Prefer not to answer
Additional Note or Comment
Optional Information: My annual income is...
0-$5,000
$5,000-$10,000
$10,000-$15,000
$15,000-$20,000
$20,000-$30,000
$30,000-$40,000
$40,000-$50,000
$50,000 and higher
Prefer not to answer
Additional Note or Comment
Is there anything else you want the DRC to know?
Yes (Specify Below)
No
Additional Note or Comment
A successful submission of this form will send an automatic email to your Bellevue College (BC) Email address. Please be sure to check your email regarding next steps.
*
(Selection is Required)
I acknowledge and will check my BC Email.
Additional Note or Comment
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