Disabilities Disclosure and Accommodation Request

This form should be completed when a student has indicated his or her desire to request reasonable accommodation(s)* from the college for a learning, physical or psychological disability.** This disclosure and accommodation request is for the purpose of allowing the student to meet and perform the academic standards of an educational program or activity or to enjoy equal benefits and privileges of education as are enjoyed by similarly situated students without disabilities.

Name(Required)

First Middle Last

Home Phone

Please enter a valid phone number.

Cell Phone(Required)

Please enter a valid phone number.

Email(Required)

Student ID

Enter last six digits. Only list if a current student.

Birth Date(Required)

Home Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Identify and describe the physical, learning or psychological disability, illness, condition or disease that is the basis for your request for reasonable accommodation(s) by the college. Be specific:(Required)

Describe how this disability affects your academic work, class schedule, class location and/or residential living situation:(Required)

Identify and describe the reasonable accommodation(s) being requested to enable you to meet or perform the academic standards of your educational program:(Required)

Identify and describe any equipment, aids and/or services that you currently use and are willing to provide and/or utilize:(Required)

Please be prepared to submit current documentation (not older than three years) of your disability, including clear recommendations for accommodations from a professional care provider.

Information concerning your disability will be treated confidentially and will be shared with staff at the college on a need to know basis. By checking “Yes” below and signing this form, you give Montreat College permission to share information concerning your disclosed disability and request for reasonable accommodation(s) with campus professionals who need to know (such as professors, advisors, counselors, Residence Life/Student Life Staff, or Dining Hall Staff) and to work with you to complete an Accommodation Plan for you to give to your professors and advisor and other appropriate campus officials.(Required)

Yes, I request assistance in arranging for my reasonable accommodation(s)

No, I am not requesting accommodation at this time

Accommodation Request

Academic year for accommodation(Required)

Enter in this format: 2022-23

Residence Hall(Required)

Only list if a current student.

Room Number(Required)

Only list if a current student

Student Classification

Freshman

Sophomore

Junior

Senior

What type of assistance are you seeking?

Academic

Residential/Housing

Meal Plan

Emotional Support Animal (ESA)

Other

Briefly describe the accommodations you are requesting.(Required)