Student Request for Reasonable Accommodations Application

* indicates a required field

Personal Information

Please enter your information
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Please use your university issued email address
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Gender



Optional - For statistical purpose only

Placement Test

Are you requesting accommodations on Accuplacer?
(the test is not timed)

Disabiity Related Information

THIS SECTION MUST BE COMPLETED FULLY
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Please check all that apply
Acceptable Forms: IEP, 504 Plans, and Evaluations

Academic Information

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Vocation Rehabiitation Information

Do you receive services from Vocational Rehabilitation or some other office of rehabilitation services?
If no, would you like assistance contacting VR for possible funding of services?

Certificate Information

Certificate Information
By checking this box, I give permission to the staff of Student Disability Services to contact my parents and/or legal guardian and my diagnosing healthcare professional in their attempt to verify my eligibility for academic accommodations.

I understand that this permission extends to the verification process only.
 

Disclosure Information

Disclosure Information(Required) *
By completing and signing this intake application, the signer is voluntarily disclosing a disorder and requesting accommodations. Disclosure of a disorder at this time does not necessarily confirm eligibility status for services or accommodations. While the Office of Student Disability Service will make every attempt to quickly review all requests for accommodations, the verification process may take several weeks or longer, depending upon the comprehensiveness and currency of the documentation submitted.
 
All information submitted to this office is to be completely confidential and used only for the purposes of verification and in connection with this institution’s commitment and obligation to students with disabilities.
 
By checking the box below, you confirm that you have read (or have had read to you) and understand this document.