Access Services Accommodation Request

Student Information

Please enter your information

First Name

Last Name

Middle Name

Student ID

Email

Please use your university issued email address

Cell Number

Alternate Phone Number

Specific Accommodation Information

Academic accommodations are requested due to the following diagnosed disabilities

Check all that apply

If Learning Disability, Psychological Disability, Health or Medical Impairment, or Other were selected, specify here.

Please give a brief description of how the above disability impacts your educational experience.

Release of Information

I hereby authorize and request that Dr. Rebecca Jones, Assistant Vice President, Student Success and Wellness, the Dean of Arts and Sciences, or the Dean of Pharmacy be able to release and/or obtain all confidential information acquired in the course of the evaluations and treatments of my disability. This information is to be solely used for the purpose of providing academic accommodations. I give Dr. Rebecca Jones, or the Deans' Offices my permission to speak with the following people on my behalf, regarding academic accommodations, without my need for additional consent:

Release of information is authorized for the following parties:

If "other" specify here

I understand that I may revoke this authorization at any time by informing the above parties in writing, except to the extent that prior action has been taken on it. This authorization will expire on December 18, 2018.. I will need to renew this release each semester in order to continue receiving accommodations.

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Access Services Accommodation Request

Student Information

Specific Accommodation Information

Release of Information

Document Information