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

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?*

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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