Accommodation Request Form

Disability Information (Please select all that apply):*

Learning DisabilityMobility ImpairmentVisual ImpairmentDeafness or Hearing LossNeurological ConditionMedicalBrain InjurySpeech and Language ImpairmentPost Traumatic Stress Disorder (PTSD)ADD/ADHDAutism Spectrum DisorderTemporary (specify)Other (specify)

If other, please specify:

In your own words, please also provide some additional details about your disability/disabilities and how it affects your ability to function within an academic setting.

Accommodations

What accommodations have you used in the past?

Please list the accommodations/services you are requesting:
Alternative testing (e.g. extended time, quiet location, alternative format, etc)Alternative textbook format (e.g. braille, e-text)InterpretingFM SystemAccessible audio/video materialsAccessible furniture within classroomPriority seating within classroomOther

If applicable, please list any adaptive technology you will be using:

Please provide any additional information that we may need to be aware of in considering your accommodation request

The Disability Services policy is located within the student handbook.

I hereby give permission for the MUIH Disability Services to notify my instructors should I be granted accommodations in accordance with MUIH policy and applicable federal laws (i.e., Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act of 1990 and the ADA Amendments Act of 2008).