Accommodation Request Form

Student Disability Office

Accommodation Request Form

* Indicates a required field.


Student ID #:*		contact your Academic Counselor if you do not know your student id.

Name:*	First Name:	Middle Name:	Last Name:

Phone #:*		(xxx-xxx-xxxx)
E-Mail:*

Mailing Address:*
	City:	State:	Zip Code
	Country:

Student Type:*	UndergraduateGraduateDoctoral

Course Type:*	OnlineGround

Current Date:	5/16/2012

Classes begin:*

The need for accommodation:*

1. Hearing Impairment4. Vision impairment/blindness
2. Mobility impairment5. Other: please explain below
3. Learning Disability

Describe the Accommodations You Are Seeking:

Please check this box if you plan on requesting any eBooks.

Please note: You may need different accommodations for different courses throughout the semester. If you find this to be true, please contact the Student Disability Officer. If your schedule changes, please notify the Student Disability Officer of the change as soon as you can. New accommodations cannot take effect until we hear from you.
please submit questions to disabilityoffice@gcu.edu