Request for Accommodations

* indicates a required field

Student Information

Please enter your information

First NameRequired *

Last NameRequired *

Preferred Name

Middle Name

Student IDRequired *

EmailRequired *

Please use your college issued email address

Cell NumberRequired *

Preferred Pronouns

Are you completing this form with the assistance of someone else?Required *

Are you completing this form with the assistance of someone else? Yes Are you completing this form with the assistance of someone else? No Are you completing this form with the assistance of someone else? With the Accessibility Services Coordinator

I am a...Required *

Parent Name and phone numberRequired *

Student Type

{"display_name":"Student Type","hidden_field_name":"ms_field_1","init_id":"ms_field_1","init_link":"","has_autocomplete":false,"has_hierpicklist":null}

Emergency Contact Name, Phone Number, & Relationship to you

Primary Campus Location

Are you requesting accommodations for placement testing to be enrolled?Required *

Are you requesting accommodations for placement testing to be enrolled? Yes Are you requesting accommodations for placement testing to be enrolled? No

Is the student registered for a college level class?Required *

Is the student registered for a college level class? Yes Is the student registered for a college level class? No

Are you registered for a class?Required *

Are you registered for a class? Yes Are you registered for a class? No

Semesters Registered

Check all that apply

Summer Fall Spring

What is the name of the class(es)? If an outside agency exam is required, what is the name of the exam?Required *

Which continuing education class(es) are you registered for?Required *

Please include the name of the course, instructor, class meeting day/time. If you are registered for more than 1 course please include all classes.

Would you like to meet with a Career Counselor?

Would you like to meet with a Career Counselor? Yes Would you like to meet with a Career Counselor? No Would you like to meet with a Career Counselor? Already met with one/Scheduled to meet with one

Service Animal Registration

Will you be utilizing a service animal on campus due to your documented disability/diagnosis/medical condition?

Will you be utilizing a service animal on campus due to your documented disability/diagnosis/medical condition? Yes Will you be utilizing a service animal on campus due to your documented disability/diagnosis/medical condition? No Will you be utilizing a service animal on campus due to your documented disability/diagnosis/medical condition? N/A

Service Animal Type/BreedRequired *

Service Animal Name

Is the work or tasks performed by a service animal directly related to your disability or medical condition?

Is the work or tasks performed by a service animal directly related to your disability or medical condition? Yes Is the work or tasks performed by a service animal directly related to your disability or medical condition? No

What work or task has the above named service animal been trained to do?

As the student, are you the trained handler for the service animal?

As the student, are you the trained handler for the service animal? Yes As the student, are you the trained handler for the service animal? No

Does your service animal have a badge or harness identifying that the animal is for service?

Does your service animal have a badge or harness identifying that the animal is for service? Yes Does your service animal have a badge or harness identifying that the animal is for service? No

Any additional information that should be known regarding the above named service animal

Educational Background

Please provide us with information about your education by answering the questions below.

Please select the highest level of education/grade you have completed?Required *

Name of High School (if applicable)

Did you have an IEP or 504 Plan while in high school?

Did you have an IEP or 504 Plan while in high school? Yes Did you have an IEP or 504 Plan while in high school? No Did you have an IEP or 504 Plan while in high school? I don't know

If you had an IEP or 504 Plan in high school, can you provide this office with a copy of it?

If you had an IEP or 504 Plan in high school, can you provide this office with a copy of it? Yes If you had an IEP or 504 Plan in high school, can you provide this office with a copy of it? No

What assistive technology/devices, if any, have you used in education?

(ie. Chromebook, iPad, Screen Reader, Hearing Amplifier, LiveScribe Pen, etc.)

Do you feel comfortable using a computer to complete coursework?

Do you feel comfortable using a computer to complete coursework? Yes Do you feel comfortable using a computer to complete coursework? No

Diagnosis/Medical Condition/Disability & Documentation

In this section please provide specific details about your diagnosis, and how it impacts your ability to function in an educational setting.

So that we may best understand your needs, please indicate the area (s) for which you are requesting accommodations?Required *

What major life activity(ies) is (are) negatively impacted by your diagnosis (with our without accommodation)?Required *

Cognitive Ability (Thinking) Talking/Speech Reading Walking/Mobility Writing Math Other Physical Activities Other

Please explain your answers listed above by describing how your disability impacts your performance as a student.Required *

Do you have documentation of your condition from an appropriate clinical professional (doctor, psychologist, audiologist, etc.)?Required *

If yes, please upload the documents below or email a copy to disabilityservices@davidsondavie.edu.

Do you have documentation of your condition from an appropriate clinical professional (doctor, psychologist, audiologist, etc.)? Yes Do you have documentation of your condition from an appropriate clinical professional (doctor, psychologist, audiologist, etc.)? No

Upload supporting document(s)

Provide information for the professional providers who can provide documentation to Accessibility Services.

If you would like us to reach out to your provider on your behalf for your documentation, please include the name(s), phone number(s), and fax number(s) for each. Professional providers may include: medical providers, psychologists, educators, VR professionals, etc.

Accommodations

In the following questions, please indicate the type of accommodations you believe that you need in college, or that you have used in the past in an academic setting.

Please indicate the type of accommodation(s) you believe that you need in college, or have used in the past.Required *

Alternative Print (Large, Braille, Audio) Changes in Seating Arrangement Personal Care Attendant Use of a service animal Extended Time Separate Distraction Free Testing Use of Assistive Technology Note-taking assistance Interpreter for Language (ie. American Sign Language) Hearing aid or amplifying device Record Lectures Other

Please indicate the type of accommodations you are seekingRequired *

Please be sure to submit this form at least 24 hours in advance of the event so we can ensure accommodations can be provided.

Please explain your answers above, and indicate any other accommodations you may be requesting from Accessibility Services.Required *

What vent are you attending?Required *

What is the date and time of the event?Required *

Learning About You

Accessibility Services uses this section to learn more about you as a student to help determine what other resources could help you through your college experience.

Do you work with a Vocational Rehabilitation Counselor in the community?Required *

Do you work with a Vocational Rehabilitation Counselor in the community? Yes Do you work with a Vocational Rehabilitation Counselor in the community? No

If yes, do they assist you with paying for college?

If yes, do they assist you with paying for college? Yes If yes, do they assist you with paying for college? No

Would you like to talk to someone about Financial Aid options?Required *

Would you like to talk to someone about Financial Aid options? Yes Would you like to talk to someone about Financial Aid options? No

How do you learn best?

Eyes Ears Hands Combination

Are you comfortable self-advocating for your needs?Required *

Are you comfortable self-advocating for your needs? Yes Are you comfortable self-advocating for your needs? No

Would you like assistance with learning how to self-advocate?Required *

Would you like assistance with learning how to self-advocate? Yes Would you like assistance with learning how to self-advocate? No

Would you like assistance with learning about good study habits?Required *

Would you like assistance with learning about good study habits? Yes Would you like assistance with learning about good study habits? No

What time of day are you most focused and productive?

What is your easiest subject?

What is your hardest subject?

Would you be interested in tutoring assistance?Required *

Would you be interested in tutoring assistance? Yes Would you be interested in tutoring assistance? No

Which of the following do you have difficulty doing?Required *

Check all that apply

Paying attention in class Completing assignments Taking notes Memorizing Managing your time Reading at a good rate Understanding what you read Proofreading - (Writing something and going back to find errors) Doing math calculations Doing math word problems Following directions Spelling Finishing test on time Putting thoughts into words Being motivated

Would you attend workshops or sessions about your difficult areas?Required *

Would you attend workshops or sessions about your difficult areas? Yes Would you attend workshops or sessions about your difficult areas? No

Please type any additional information that you would like to share with the Accessibility Services Coordinator.