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Request an Accommodation
Request an Accommodation
*
= required field
Contact Information
Full Name
*
Preferred Pronouns:
*
Birth date (MM/DD/YYYY)
Student I.D. Number
*
Email Address
*
Expected Graduation Date
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2021
2022
2023
2024
2025
2026
Disability Information
What Brings You to Disability Services?
I am looking for information - I want to know what my options are.
I am looking for possible accommodations.
Other (Specify below.)
Description of Disability: Check all conditions in which you have been officially diagnose with supporting documentation.
*
Learning Disability
ADD/ADHD
Mobility Impairment
Chronic Health Impairment
Psychiatric/Behavior/Mental Health Impairment
Visually Impaired/Blind
Hard of Hearing or Deaf
Autism Spectrum Disorder
I do not have an official diagnosis, but I am seeking additional support.
Please describe how your diagnosed condition impacts you.
What has been helpful in removing your barriers that impact you.
Have you ever received accommodations or educational services in the past?
*
--
Yes
No
What accommodations are you looking for?
*
Additional Note or Comment
Please note: Accommodations will be discussed in person in a meeting with the Disability Services staff member. A member of the Disability Services team will contact you after you submit this form.
I understand I must meet with Disability Services and provide documentation of my disability in order to be eligible to receive accommodations. I give consent to Disability Services to access my student records at Luther College. Additionally, I give consent for Disability Services to retrieve, review, and share information with my medical provider(s) to determine eligibility for services. I certify that the above information provided is accurate. Please reply with "Yes" in the field below to agree to this statement.
*
Tarbabypre
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Tarbaby
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Noturl
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Antlion
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