STUDENT SUCCESS SERVICES REGISTRATION FORM

How to Register with Student Success Services - Accessible Learning Services

Step 1: Complete the Registration Form

• Complete this form if you would like to register with Student Success Services

Step 2: Provide your Supporting Documentation

• You will be asked to provide documentation from a regulated health care professional that confirms a disability. The documentation will be used to provide appropriate accommodations and supports to meet your needs.

• Interim or temporary accommodations may be provided for students who are in the process of being assessed for a disability, or experience an episodic disabling event.

Step 3: Book an Appointment

• Once your form is submitted, you will be contacted to schedule an appointment for you to talk to a Student Success Navigator. "

If you do not have a disability but require support from Student Success Services, please complete the Support Services Request Form

First Name

Last Name

Preferred First Name

Student ID

Primary Email

Please use your preferred email address

Alternate Email

Registration

Please indicate why you would like to register with Student Success Services

Check all that apply

Reason for registration, other:

Have you previously been registered with Student Success Services?

Privacy

Please review the statements on privacy and confidentiality and select "I have read and understand" below to acknowledge receipt of this information.

Freedom of Information and Protection of Privacy

All information shared with Student Success Services will not be released without your written consent. Student’s personal information is held in utmost confidence within Student Success Services. Personal information including medical documentation and psycho-educational assessments are collected in order to understand student needs and determine reasonable disability accommodations and to meet our requirements under the Ontario Human Rights Code. Personal information is maintained and disposed of in a secure manner, in compliance with relevant privacy legislation. Information provided to Student Success Services is stored separate from a student’s academic record in order to protect a students’ right to privacy. All Student Success Services team members with access to student files maintain strict levels of privacy and confidentiality.

Gender Pronoun

Birth date (DD/MM/YYYY)

Primary Phone

May we leave a message?

Alternate phone

May we leave a message (Alternate Phone)?

Preferred Method of Contact

Address While in School

If you do not know this please put current address.

May we email you regarding upcoming appointments and disability related events?

Emergency Contact

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Home/Residence Phone

Emergency Contact Cell Phone

Student/Program Status

International Student

First Nation, Inuit, Métis

My college education will be funded by:

Status

Anticipated Start Date

Program Status

Program

Campus

Disability

Where available, attach supporting documentation from a doctor, a psychologist or other registered healthcare professional. The documentation should indicate the type of disability (DSM diagnosis is not required), the expected permanence of your disability as well as the physical, cognitive and behavioural impacts on your daily functioning.

Do you have Disability Documentation?

To better assist you, choose one or more categories that best describes your disability(s) using the following choices:

Additional information you would like to share

Upload supporting document(s)

Students with permanent or temporary disabilities who require academic accommodations are encouraged to register with the Student Success Services (SSS).

SSS will accept a variety of documentation to determine eligibility for academic accommodations, depending on the nature of your disability.

To obtain the most recent disability documentation available, you may wish to contact:

• Your family doctor, medical specialist, psychiatrist, psychologist/psychological associate, ophthalmologist, audiologist or other Regulated Health Care Professional (RHCP)

• The high school or school board where you last attended (IEP, Psychoeducational Assessment)

• Your disability service provider if you are sponsored through an external referral/sponsoring source such as W.S.I.B.

Interim (temporary) accommodations, until we receive appropriate documentation, are possible.

For more information, contact (705) 474-7600 x 5205 or email studentsuccessnow@canadorecollege.ca

Email Consent

I am consenting to email correspondence and electronic transmission of documents.

STUDENT SUCCESS SERVICES REGISTRATION FORM

Registration

Emergency Contact

Student/Program Status

Disability

Document Information