Request for Accommodation of Disability

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This form should be completed and signed by the student.

Name

Date

Email Address

Physical Address

Phone

What is your status at Washington and Lee

Incoming First-year Student Incoming Transfer Student Current Washington and Lee Student

Class Year

When was the most recent evaluation of your condition and who conducted the evaluation?

In your own words, please describe your disability and how it affects your ability to fully access a University program or activity.

Does your disability necessitate any special or additional assistance during an emergency (i.e., assistance in receiving effective emergency communications or assistance in evacuating a building)?

No Yes

If yes, please explain.

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

SAT

ACT

TOEFL

High School

Other Undergraduate College

Other, please specify.

What accommodations have you previously used?

What accommodations are you requesting at Washington and Lee? Please describe how each requested accommodation relates to your disability.

Please provide any additional information you feel would be useful when considering accommodations that may be needed at Washington and Lee.

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.