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REQUEST FOR ACCOMMODATIONS

Personal Information

Name: *

CWID: *

Address: *

DOB: *

Month

Day

Year

Phone: *

ULM Email: *

Racial/Ethnic Background: *

Gender: *

Marital Status: *

Referred by: *

Self

Friend

Faculty

Staff

Other

Other:

Academic Information

Class Year: *

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 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.

Student’s Name

Date:

Month

Day

Year

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