Request for Accommodation Application

This accommodation form should be used by students, faculty and staff for all accommodation requests including; academic/learning, housing, dining, and workplace accommodations. The applicant must complete and submit the online form below (step one) and must also supply appropriate supporting documentation to the Office of Accessibility Services (step two). Upon receipt of a completed application, the Office of Accessibility Services will contact the applicant to set up an appointment to discuss the application and the outcome of the review. Please note that completing this application does not guarantee the approval of any accommodation. Reasonable and appropriate accommodations, academic adjustments, and/or auxiliary aids and services are determined on a case-by-case basis for otherwise qualified individuals who have a demonstrated need for these services and can provide appropriate documentation.

First Name *

Last Name *

Address

Street Address

Address Line 2

City

State

ZIP / Postal Code

Country

Phone

Email *

Birthdate

Month

Day

Year

Major (if applicable)

Campus Activities/Interest Groups/Clubs

Please check all that apply to your request: *

Learning/Academic/Classroom Accommodation

Dietary/Dining Hall Accommodation

Residential Accommodation/ADA Compliant Room

Physical Modification (Classroom/Lab/Field Work)

Workplace/Employee Accommodation

Other (Please Explain)

Please check all that apply to your request: Other (Please Explain)

Please include below the nature of your disability, a description of all current limitations, and the specific accommodations that you are seeking. Please include any relevant history regarding your disability, any past accommodations that were helpful to you, and any other information that you feel would be helpful. *

Our commitment

William Jewell College is committed to ensuring that educational opportunities, programs, and services offered by the College are available and accessible to all individuals in accordance with Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 as amended in 2008, and the Fair Housing Act. If you need assistance in completing this form please email accessibility@william.jewell.edu.

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