Accessibility Services Registration

Student Information

Please enter your information

Privacy/Confidentiality Statement

Accessibility Services (AS) collects student personal/health information only as is reasonably required to confirm service eligibility and provide appropriate supports. When we collect, use, or disclose student personal/health information, we follow applicable Saskatchewan Polytechnic (SPT) policies and the laws with which they comply. For more information about our obligation to protect your privacy/confidentiality, please see SPT’s Privacy/Access page.

Purpose/Use of Student Intake Form

This form requires you to share a certain amount of personal/health information. We will use this information to create your AS registration record and to facilitate your first meeting with an accessibility counsellor. We will also use it to assist us in providing services/supports tailored to your needs.

First Name

Last Name

Middle Name

Preferred Name (optional)

Preferred Gender Pronoun (optional)

Student ID

Sask Polytech (SPT) Student ID Number

Email

Please use your Sask Polytech (SPT) issued email address

Alternate Email Address

Phone Number

First Language

Second Language(s)

Program Status

Program Location

Please select your program location.

Start Date of Studies

Method of Study

Educational History

What is your highest level of education?

Have you ever attended Sask Polytech before?

Medical/Disability-Related Documentation

AS requires adequate medical/disability-related documentation* to confirm student eligibility for services/supports.

For more information about documentation criteria, please visit this page.

Regarding the need for adequate documentation, please check the box that best describes you:

Regarding the need for adequate documentation, please check the box that best describes you: I submitted my documentation prior to completing this Form Regarding the need for adequate documentation, please check the box that best describes you: I will submit my documentation along with this Form Regarding the need for adequate documentation, please check the box that best describes you: I will submit my documentation as soon as it is available Regarding the need for adequate documentation, please check the box that best describes you: I previously submitted my documentation to SaskPolytech Regarding the need for adequate documentation, please check the box that best describes you: I have a disability, but my documentation is missing Regarding the need for adequate documentation, please check the box that best describes you: I have a disability, but my documentation does/may not meet all the necessary criteria (Please submit whatever you have) Regarding the need for adequate documentation, please check the box that best describes you: I suspect I may have a disability

Self-Assessment of Academic Needs

Academic Supports

In your educational career, have you ever had any extra academic supports (e.g. specialized programming; notetaking supports; reading/math supports; tutoring) or exam supports (e.g. extra time; separate room; exam reader)?

What sorts of challenges do you experience when it comes to learning/succeeding in school?

How do you manage the challenges you self-identified above?

For example: coping strategies, assistive technology, personal counselling, other supports?

What accommodations/extra supports do you think you will need at SPT based on your identified learning/academic challenges?

Preliminary Assessment of Funding Needs

How are you funding school (check ALL applicable)?

Please list funding sources here

Telehealth Consent

Please bring any questions you have about the telehealth consent to your appointment. Your Accessibility Counsellor will review the telehealth consent with you and if wish to withdraw your consent at any time you can discuss this with your Accessibility Counsellor.

Consent to use Electronic Communications to Provide Telehealth Services

I acknowledge that in consenting to having Accessibility Services, Saskatchewan Polytechnic, communicate with and/or provide services through email, text, Zoom, and/or telephone, that I am aware of the following:

Risks of using electronic communication

While Saskatchewan Polytechnic Accessibility Services will use reasonable means to protect the security and confidentiality of information sent and received using electronic communications, because of the potential risks as outlined below, we cannot guarantee the security and confidentiality of electronic communications.

Use of electronic communications to discuss sensitive information may increase the risk of such information being disclosed to third parties.
Electronic communications are subject to disruptions beyond the control of Accessibility Services that may prevent being able to provide the service.
There may be limited services that can be provided through electronic communications, dependent on the means of electronic communications being utilized.
Despite reasonable efforts to protect privacy and security of electronic communication, it is not possible to completely guarantee the security of the information. Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of Accessibility Services or the student.

Conditions of Using Electronic Communications

Electronic communication may not be an appropriate substitute for some services that Accessibility Services offers.
Electronic communications will not and should not be used for medical emergencies or other time-sensitive matters.
The student will inform Saskatchewan Polytechnic Accessibility Services with any changes to email address, phone number, or other student information necessary to communicate electronically.
Electronic communications may be copied or recorded in full or in part and kept as part of the student’s confidential file with Accessibility Services.
The student will take precautions to preserve the confidentiality of electronic communications, such as using screen savers and safeguarding computer passwords.

I acknowledge that I have read and fully understand the risks, limitations, conditions of use, and instructions for use of electronic communications as described above. I acknowledge that this is an addition to the original Consent Form that I have previously signed. I acknowledge and agree to communicate with Saskatchewan Polytechnic Accessibility Services using these electronic communications with full understanding of the potential risks in doing so.

Telehealth Consent Signature

Telehealth Consent Date

Confirmation of Form Completion

Student Signature

In signing this form, I acknowledge my consent to Accessibility Services’ collection, use and disclosure of my personal information, as outlined above.

Form Completion Date

SCBScN Students Only

I understand that in order to receive accommodations at both Saskatchewan Polytechnic and the University of Regina, I will need to register at both institutions. I give permission to Accessibility Services to collect and share information with University of Regina, Centre for Student Accessibility in order to ensure consistent support in the Collaborative Nursing program (SCBScN). I understand the above statement and agree to allow Accessibility Services at Saskatchewan Polytechnic to collect and share information with University of Regina Centre for Student Accessibility.

University of Regina Intake

In addition to this intake, please fill out the intake with the University of Regina Centre for Student Accessibility

Upload supporting document(s)

Document verifying disability guidelines can be found here

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