Student Accommodation Request

* indicates a required field

Student Information

Please enter your information. Student should complete this entire form, not a representative of the student.
ex: Fall 2020

Section 1: Health and Accommodation Information

ex: Learning Disorder, ADHD, Epilepsy, Arthritis, Major Depressive Disorder, etc.
year, age, or grade

For a list of commonly requested accommodations, please visit our website.

Are you requesting a housing-related accommodation?(Required)

Section 2: Impact

Please describe any ways in which your disabilities impact you in the following areas. If not relevant to your condition, type N/A
Including: reading, writing, math, spelling, listening, and note taking.
Including: organization, time management, memory, concentration, and managing distractions.
Including: managing stress, frustration tolerance, and social interaction.
Including: walking, talking, hearing, seeing, sleeping, and writing quickly.

Section 3: Free Response

Please include anything about yourself not covered here or in the documentation you submit.

Section 4: Consent to Release & Documentation

DASS staff may find it helpful to consult with others about your disability and request for accommodations. To grant permission, check “Yes” and list the names of the individual(s) in the field.
Parent(s)/Legal guardian(s)
Diagnostician who diagnosed the disability
Other medical professionals
Include all medical and psychological documentation, school records (high school or other college accommodation plans), or reports. Failure to submit all available records may delay your request. Review our documentation guidelines for more details.