Fred Smithers Centre

Please Read Carefully Before Proceeding

Please complete the following application if you wish to receive services through the Fred Smithers Centre of Support for Students with Disabilities. Your application will be processed based on the date received and our ability to provide the supports requested. Documentation of a disability must be provided. Some applicants may not be eligible for support services.

Last Name
First Name
Date of Birth
E-mail

Local Address

Street


City


Province / State


Postal Code


Phone


Cell
Mailing Address (if different than Local)

Street


City


Province / State


Postal Code


Phone
 
Preferred Method of Contact
 

Program

Student Number (if known): A
Are you visiting from another institution?    
If yes, which institution?
 
Anticipated SMU start date (e.g., Sept 2012):
High School Attended:
Year of Graduation:

Disability Information
 


Please specify:



Please specify:

Please specify:



Please specify:
 
Do you have documentation of your disability?      
PLEASE NOTE: You will be asked for documentation of your disability. Your application will not be processed until we receive documentation

Please check supports and accommodations that you have used in the past and found helpful:
 

 

You will be contacted for an interview by a representative of the Fred Smithers Centre.