Accessibility Services Application

Name *

First

Last

Student ID Number

Academic Year *

Email *

Primary Phone *

Program(s) of Study *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

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Emergency Contact Name *

First

Last

Emergency Contact Phone *

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Please describe your diagnosis: *

Please indicate accommodations you may need (check all that apply): *

Please note accommodations requested will be reviewed and approved based on documentation received, best practices, and ADA higher education requirements.

Other accommodations needed:

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Current treating clinician/ doctor(s): *

First

Last

Title *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Current medications (please include dosage/ frequency): *

Previous accommodations (if any): *

How does your diagnosis impact you academically? (i.e. concentration, note taking, etc.) *

How does your diagnosis impact you in your everyday life? *

Supporting Documentation

Click or drag files to this area to upload. You can upload up to 5 files.

Please submit any relevant documentation in accordance with the documentation guidelines on the Accessibility Services page of our website.