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Accommodation Request
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Student Information
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First Name
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Last Name
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Middle Name
Student ID
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Email
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Please use your university issued email address
Cell Phone
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Home Phone
Work Phone
What is the best way to reach you?
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Cell Phone
Home Phone
Work Phone
E-mail
Disability Information
In this section, provide information related to your disability, including what reasonable accommodations you are requesting. Additional accommodations can be requested at any time through communication with DASS.
State your specific disability, or disabilities, and approximate date of most current evaluation.
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Current, formal documentation is required and can be uploaded below.
Please select if either of these apply:
I have not be diagnosed with a disability
My diagnosis is in progress
Describe how your disability might affect you ability to function in the college setting
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Describe what reasonable accommodations you are requesting.
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Upload supporting document(s)
Upload supporting documentation regarding your disability. This can also be submitted through fax, e-mail, or in-person in the DASS office.
Document Information
Document Title
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File
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Maximum file size: 10240kb
Description