Request for Accommodation of Disability

You have three options for completing this form:

  1. Download the PDF, print it out, and complete by hand.
  2. Download the PDF, open it in your favorite app to fill out and submit either by printing or emailing.
  3. Complete the form below that upon clicking the button, will fill out the PDF and download it for you so you can print or email the form accordingly.

This form should be completed and signed by the student.

Have you received disability accommodations in the past from any of the following?

I authorize and request the Title IX Coordinator and Director of Disability Resources to consider this request for accommodations and copies of all documentation provided in connection with this request and, only as he/she deem(s) necessary for the evaluation and/or implementation of my eligibility/accommodation, to consult with other educational, medical, or psychological professionals, disclosing such information as he/she/they deem(s) relevant for consultation. I consent to the Title IX Coordinator and Director of Disability Resources discussing this request and all evaluations and assessments pertinent to my disability with any diagnosing/evaluating professionals.

Note: This request cannot be acted upon until you provide documentation of the disability as outlined in the Documentation Guidelines, which are available online.