Please identify and explain any disabilities you have.
____ I do not have any disabilities.
____ Speech Impairment:
____ Hearing 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.):
____ Heart Disease with restriction of activity:
____ Blood Disease:
____ Pulmonary or resperatory disorders (e.g. tuberculosis, emphysema, asthma):
____ Kidney dysfunctioning:
____ 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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