Student Support Plan Request

Student Name*

First Last

Student ID*

Phone*

Email*

Student Type*

Traditional Undergraduate
Graduate, Adult & Professional, or Online

Academic Major*

Type of Disability*

Meal Plan Accommodation*

Exemptions from the meal plan are rare and only in the case of documented health conditions* that require special diets which otherwise cannot be accommodated by the food service provider. *Medical documentation must be from a recognized professional (M.D.) with expertise related to condition.

Yes
No

Housing Accommodation*

Important: Returning Students must apply for housing accommodation by June 1st, to be considered for housing accommodations for the following Fall semester. New incoming students are expected to submit disability-related housing requests with as much notice as possible to provide ample time for housing coordination. At least 60 days prior to move-in date is preferred.

Yes
No

Classroom Support

If you are seeking a form of accommodation please indicate by checking the boxes below and provide in detail what type of support you may need.

Support Type

Note Taker
Interpreter
Digitized Texts
Seating Accommodations
Adaptive Equipment
Testing Accommodations
Curriculum Modifications
Other

Note Taker Details

Peer/ Student Note taker (Carbon Copy of lecture notes)
Electronic Platform (i.e. Sonocent, Livescribe Smart Pen, etc.)

Interpreter Details

Digital Texts Details

Seating Accommodations Details

Adaptive Equipment Details

Testing Accommodations

Extended Time on Test
Alternative Testing Environment

How much time on tests?

What type of testing environment?

Curriculum Modification Details

Other Details

Desire/Permission to share with Parents/ Guardians*

By clicking yes, you are giving us permission to share your information with Parents/Guardians

Yes
No

Desire/Permission to share with professional staff*

By clicking yes, you are giving us permission to share your information with Professional staff

Yes
No

Do you prefer a typed signature?*

By selecting this option you approve a typed signature rather than a digital written signature.

No
Yes

Student Typed Signature*

Student Signature*

If signature area not visible click the refresh icon under the "Student Signature" label.

Name

This field is for validation purposes and should be left unchanged.