Request For 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

What type of accommodations are you requesting? (Select all that apply)

Academic

Residential

ESA

Elevator

Type:

Permanent

Temporary

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

List the accommodations you are requesting in an academic setting. (Write N/A if not applicable) *

List the accommodations you are requesting in a university-owned residential setting, if applicable. (Write N/A if not applicable)

Describe auxiliary aids, assistive technology and/or services that you anticipate using while attending ULM, if applicable. (Write N/A if not applicable)

Describe your need for Elevator access and the medical condition for the need. (Write N/A if not applicable)

Medical Condition:

Accommodation History

Disability Accommodations and/or Services used in High School: (Write N/A if not applicable)

Colleges/Universities Attended: (Write N/A if not applicable)

List Disability Accommodations and/or Services Used There: (Write N/A if not applicable)

Certification

Certification *

I certify that the information provided on this form is accurate. I understand that to be eligible for accommodations at ULM, I must 1) submit this completed form, 2) submit disability documentation that substantiates the requested accommodations. My signature authorizes the Office of Student Accessibility Services to discuss my documentation with the clinician who authored the documentation if additional information or clarification is required.

I understand that a request for services does not guarantee services to be approved.

I understand that it is my responsibility to provide sufficient documentation in a timely manner to complete the process for approval of accessibility services to be granted. Students seeking to utilize approved accommodations should submit their request no later than the end of the drop/add period.

Student’s Name *

Date: *

Month

Day

Year

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