Temporary Academic Accommodation Request Form

Disability Services at Montreat College supports students with temporary disabling conditions that may have resulted from injuries or short-term medical conditions on a case-by-case basis. Examples of temporary disabilities may include, but are not limited to concussions, broken limbs, or hand injuries.

Complete the following steps in order to request temporary academic accommodations:

Complete and submit the Temporary Academic Accommodation Request Form. (If you have an injury or have had surgery that impacts your ability to type and would like help with completing the form, identify yourself to Ashley Rhymer in the Thrive Center, ashley.rhymer@montreat.edu, or ext. 3546).
Provide appropriate clinical documentation that includes the following:
- A diagnosis
- Functional limitations necessitating temporary accommodation(s)
- Estimated length of time accommodation(s) will be needed

Please submit clinical documentation with this form. If anything needs to be sent by mail, direct it to: Ashley Rhymer, The Thrive Center, Montreat College, PO Box 1267, Montreat, NC 28757.

Full Name(Required)

First Middle Last Suffix

Phone(Required)

Email(Required)

Home Address(Required)

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

Athletic Team (if applicable)

What is the nature of the disability you are requesting accommodations for?(Required)

In your own words, please describe the current impact and functional limitations of the disability (i.e. physical and/or mental):(Required)

What is the duration of your condition and how long do you anticipate needing accommodations?(Required)

Please describe your requested academic accommodations below:(Required)

Have you been seen by a medical professor for your temporary disability? Please select all that apply:(Required)

Montreat College Medical Trainer

Montreat College Campus Nurse

Outside medical professional

Information concerning your temporary 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 temporary disability and request for reasonable temporary academic accommodation(s) with campus professionals who “need to know” (professors, advisers, counselors) and to work with you to complete a Temporary Academic Accommodation Plan for you to give to your professors and advisor and other appropriate campus officials. If applicable, by checking “Yes” below and signing this form, you give Disability Services permission to consult with your coach and/or athletic trainer in order to assist with the evaluation of your request.

Yes, I request assistance in arranging for my reasonable accommodation(s) and will complete the Accommodations Request Form.

No, I am not requesting accommodation at this time.

Please attach appropriate documentation to support your request, including name, address, phone, e-mail, and fax of physicians, therapists, psychologists, or other health care providers who have information concerning your temporary disability.

Drop files here or

Max. file size: 64 MB.

Electronic Signature: Full Name(Required)

I agree and acknowledge that this document can be executed electronically and it is binding in every way as if signed by my hand. I hereby authorize the above-listed health care providers (and any others who have treated me) to release to Montreat College all medical records concerning the temporary disability disclosed herein and to provide any opinions to the college concerning my ability to (1) meet and perform the academic standards requisite to performance of the educational program or activity that is the subject of this request and (2) to enjoy equal benefits and privileges of education as are enjoyed by other similarly situated students without temporary disabilities. I certify that I have read, reviewed, and been informed of the academic requirements as outlined in the Montreat College catalog (www.montreat.edu). I further certify that the foregoing statements are complete, accurate and true to the best of my knowledge.

Electronic Signature: Date(Required)