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Full Name: 

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Student Number: 

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Address: 

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Date of Birth: 

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City: 

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State: 

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Zip

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Home Phone: 

 

Cell Phone: 

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Email: 

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DOCUMENTED DISABILITY: Check all that apply: 












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Is the above condition: 

Note: If your condition is not permanent in nature, the university is not required by law to provide any accommodations, but Student Support Services may be able to assist you on a temporary basis.

Accommodations:

Based on your disability, check the accommodations you believe you will need in college in order to have equal access. (Accommodation approval is based upon supporting documentation of a disability).

 

Instructional: 

 

Testing: 

 

Support: 

 

Environment: 

 

Equipment: 

 

Other: 

The Student Support Center must receive this form and appropriate documentation of your disability to support requested accommodations prior to consideration and provision of accommodation. Once documentation is received and reviewed, the applicant will need to meet with Student Support Center staff to discuss accommodations, procedures, and policies. Information regarding disability is kept in the Student Support Center and is considered an academic record, but is not noted in any way on the student's transcript.

Please note that the SSC may exchange information with other relevant authorities on campus to evaluate and facilitate the provision of accommodation, and signing this form, you are signifying your knowledge of and agreement with this practice.

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The practitioner who will prepare and provide documentation substantiating your request: (Both name and title)

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Address: 

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Phone: 

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Fax: 

As indicated by my signature below, permission is granted to Student Support Center Staff to exchange information with the identified practitioner (stated above) as necessary to answer questions about the documentation submitted to support this request and in consideration of my application for accommodations.

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Student Signature: 

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Date: 

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Parent or Guardian Signature if student is under 18: 

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Date: 

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By checking this box I agree that the signatures of the above student and/or guardian are who they stated

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