Learning Disabilities Program: Adelphi University

Online Application

Application for Admission to the Learning Disabilities Program
(Application Deadline for Fall Admission Is March 1)

Name:

Street Address Line 1:

Street Address Line 2:

City:

ZIP Code:

State:

Phone #:

(123-456-7890)

Fax #:

(123-456-7890)

Applicant's Email:

(name@example.com)

Parent's Email

(name@example.com)

Date of Birth:

(MM/DD/YYYY)

SS #:

(123-45-6789)

I am applying for:

Fall 2009 Spring 2009

I am a:

Freshman Transfer

Approximate # of transfer credits:

High School:

College:

Location:

Guidance Counselor:

Phone:

Are you using support services in your school: Yes No

Resource Teacher:

Phone:

Please describe your special education services and the kinds of courses you are taking
(i.e., resource room, inclusions, consultant teacher, etc.)

What accommodations do you receive?

When was your LD or AD/HD first diagnosed: (MM/DD/YYYY)

Describe your strengths:

Describe your weaknesses:

Are you declaring a major?
Major: Undeclared

Discuss your learning disability and/or AD/HD and your learning style:

Please describe any other issues or factors that may affect your ability to learn, including other co-existing diagnoses and other information that is important for us to know about you:

Why do you consider your self a good candidate for Adelphi's Learning Disabilities Program?

By completing this application, I am applying for admission to the Learning Disabilities Program, and I am aware that participation in the Program will carry additional fees payable to Adelphi University. By submitting this application, I give the Learning Disabilities Program permission to request a copy of my general admissions application from Adelphi University Office of Admissions.

11/21/2009

You can also download a printable application to the Learning Disabilities Program in pdf format. You will need Adobe Acrobat Reader to view this document.

Contact Us
For additional information, please contact:

Learning Disabilities Program
Chapman Hall, Room 7
Adelphi University
P.O. Box 701
Garden City, NY 11530-0701

p - 516.877.4710
e - ldprogram@adelphi.edu

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