Please identify and explain any disabilities you have.

____ I do not have any disabilities.

____ Speech Impairment:

____ Hearing Impairment:

____Vision Impairment:

____ Missing Extremities:

____ Nonparalytic orthopedic impairment (Because of chronic pain, stiffness or weakness in bones or joints, there is some loss of ability to move or use a part of the body.):

____ Paralysis:

____ Heart Disease with restriction of activity:

____ Blood Disease:

____ Diabetes:

____ Pulmonary or resperatory disorders (e.g. tuberculosis, emphysema, asthma):

____ Kidney dysfunctioning:

____ Cancer:

____ Mental or emotional illness:

____ Severe distortion of limbs and/or spine:

____ Disfigurement of face, hands or feet:

____ Learning Disability:

____ Other Impairments:

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