REQUEST FOR SPECIAL ACCOMMODATIONS

Personal Information

Name: *

CWID: *

Address: *

DOB: *

Month

Day

Year

Phone: *

ULM Email: *

Racial/Ethnic Background: *

Gender: *

Marital Status: *

Other:

Academic Information

Other

Entrance Date: *

Month

Day

Year

Major: *

Academic College: *

Disability Information

Please describe your disability and its impact in the university setting. *

List the accommodations you are requesting in an academic setting. *

List the accommodations you are requesting in a university-owned residential setting, if applicable.

Describe auxiliary aids, assistive technology and/or services that you anticipate using while attending ULM, if applicable.

Accommodation History

Disability Accommodations and/or Services used in High School:

Colleges/Universities Attended:

List Disability Accommodations and/or Services Used There:

Certification

I certify that the information provided on this form is accurate. I understand that to be eligible for special accommodations at ULM, I must 1) submit this completed form, 2) submit disability documentation that substantiates the requested accommodations, and 3) participate in an intake interview with the Special Accommodations Coordinator.My signature authorizes the Self-Development,Counseling and Special Accommodations Center to discuss my documentation with the clinician who authored the documentation if additional information or clarification is required.

Student’s Name

Date:

Month

Day

Year

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