Disability Support Services - Grand Valley State University

Phone: 616-331-2490
Fax: 616-331-3880

Disability Support Services
1 Campus Dr, STU 200
Allendale, MI 49401-9403

All fields are required unless otherwise specified.

First Name:

Middle Initial: (optional)

Last Name:

Date of Birth:

G Number:

(ex. GXXXXXXXX)

Gender:

Male
Female

Ethnicity: (optional)

Asian American/Asian
American India/Alaskan Native
African American/African
Caucasian
Hispanic
Multinational

Which best represents you:

Faculty
Staff
Student

Local/Campus Address

Street:

City:

State:

Zip Code:

Phone:

(xxx-xxx-xxxx)

E-Mail:

Disability Conditions: (please check all that apply)

Are you on any prescribed medication related to your disability at present?

Yes No

Are you associated with any rehabilitation service? (i.e. MI Rehab/MI Commission for the Blind)

Yes No

How did you learn about the DSS? (check all that apply)

DSS website

Union Representative

Ombudsperson

Supervisor/Unit Administrator

Human Resources

Office of Inclusion and Equity

Other