Beyond Access Application Form

Students are accepted on a rolling basis for Storrs and regional campus participation. Participation is open only to (matriculated and non-matriculated) students attending the University of Connecticut.  Submission of additional documents are required to complete enrollment. *This information will be provided after confirmation of university attendance.

Returning BA Students do NOT need to fill out this form again. Go directly to Program Agreement Forms to find the Refund Policy and the Agreement Form for your upcoming BA term.

Student Information

Student Name(Required)

First Last

Preferred Name [first]

Pronouns

e.g. She/Her/Hers, He/Him/His, They/Them/Theirs

Student Status(Required)

Current UConn Student

Transfer Student

Incoming/Prospective Student

Semester / Term of Interest(Required)

Current Semester

Upcoming Fall Semester

Upcoming Spring Semester

Summer/Winter Intersession

Current Path(Required)

Undergraduate

Graduate

Graduate/Professional Certificate

Non-degree

Cell Phone(Required)

Preferred Email(Required)

Enter Email Confirm Email

Parent/Guardian(s)/Emergency Contact(s) Names(Required)

Parent/Guardian(s)/Emergency Contact(s) Email Address(Required)

Enter Email Confirm Email

How did you find out about the Beyond Access program?

Who is completing the application?(Required)

Student

Parent/Family

Other

If other, please specify(Required)

If you are a student with a disability, how would you explain your disability to others?(Required)

What are your expectations of Beyond Access? What do you hope to get out of the program?(Required)

How would you describe your learning style (How do you learn best)?(Required)

Academics

Based on previous experiences what are your academic strengths and challenges?(Required)

What learning strategies (study methods) have worked or not worked for you in the past?(Required)

Academic areas you would like to focus on:

College Skills

Based on previous experiences, what do you identify as your strengths and challenges as it relates to college skills?(Required)

Please see the box below if you are unsure of the categories that fit

What (if any) concerns do you have about campus and/or academic participation

College skills you would like to focus on:

Learning Technologies

Learning technologies are known as “any technology used to increase, maintain, or improve the academic functional capabilities (e.g., studying, listening, planning, organizing, reading) of students.” (AT definition)

Are you currently using any learning technologies?(Required)

Yes

If Yes, what?

What technologies (apps, computer, software programs, smart phone, tablet, etc.) do you currently utilize?(Required)

What are some ways you utilize technology to help you with your academic and social obligations?(Required)

Please check off areas you would be interested in learning more about below:

UConn Web-based programs (Husky CT, PeopleSoft, etc.)

Email (etiquette, communication, etc.)

Apps/software specific to disability

Learning technologies specific to:

Reading

Writing

Notetaking

Study strategies

Website navigation

Organization and Time Management

Stress Management

Programs for specific content areas (math, science, English, second language, etc.)

Other

If selected Other, please specify:

Any additional information you would like to share with us:

Additional

POLICY REGARDING CONFIDENTIALITY AND MAINTENANCE OF RECORDS The Family Educational Rights and Privacy Act of 1974 (FERPA), as amended, is a federal law that affords students certain rights regarding their education records. Education records is broadly defined as those records, files, documents and other materials that contain information directly related to a student and are maintained by the University. For the purposes of FERPA, the University considers all students to be independent. Therefore, educational records will not be provided to parents without the written consent of the student. For additional information regarding FERPA, please refer to UConn's FERPA Website. If you are a student with a disability and have provided medical documentation to the CSD, please note the following:

The Center for Students with Disabilities (CSD) is the University agent charged with the responsibility for collecting and maintaining disability documentation.
Documentation provided to the CSD is confidential and only shared with others with the expressed written permission of the student.
All documents submitted to the CSD are scanned, stored, and maintained in the Center’s electronic case management system, which includes information about student demographics, academic programs, documentation of the disability, accommodations, and student contacts with the CSD.
The CSD electronic case management system is hosted on a secure server and is developed using industry best practices. Access to the system and its information is limited to CSD personnel only.
Once student documents are scanned and uploaded to the system, paper copies are immediately shredded.
Information will only be shared within the institutional community if there is a compelling reason, such as a threat to an individual's safety and/or emergency situation.
Consent of the student will be requested prior to releasing medical/psychological documentation to a third party. Confidentiality is not maintained in the case of child abuse, suicidal or homicidal intent.

AUTHORIZATION FOR INFORMATION RELEASE(Required)

I make the following authorizations regarding the release of information pertaining to me for the purpose of assisting me in my program, as well as in determining reasonable accommodations (if applicable).

If applicable, I permit the CSD to contact my current treating physician, psychiatrist, etc. to further discuss and/or obtain additional information regarding the nature of my medical condition, medical records and history of treatment.(Required)

Authorize

Do Not Authorize

N/A

I permit the CSD to discuss academic, medical or personal information with my parents, guardians and/or designated family member(s).(Required)

Authorize

Do Not Authorize

N/A

If any exceptions apply to these authorizations, please indicate them below:

I understand that these authorizations may be withdrawn by me at any time through a written, signed and dated request or in conference with a CSD professional staff member.

Phone

This field is for validation purposes and should be left unchanged.