Accommodation Request

Student Information

Please enter your information

First Name

Last Name

Middle Name

Preferred Name

Student ID

Date of Birth

Gender

Preferred pronouns (Example: he/him, she/her, they/them, etc.)

Please provide your permanent address

Include street, city, state, and zip code.

Example:

123 Rams Drive

Shepherdstown, WV 25443

Street Name

Include Apt/Room Number if Applicable

City

State

Zip Code

Phone Number

Email

Please use your university issued email address

Part II: Academic Information

Semester and Year of Entrance

Class Status

Enrollment Status

Housing Status

Transfer Student

Major

Advisor

Are you an international student?

Part III: Student Self Report

My diagnosed disability falls into the following category

Please select all that apply

If you selected other please specify:

Will you use a wheelchair/motorized scooter for campus mobility?

Please describe how your disability impacts your life (ex: academic, social, living). Please be as descriptive as possible:

How do you refer (or not refer) to your disability? (Ex: Person with a disability, disabled person, diagnosis, etc.)

Part IV: Accommodations

Academic/Classroom Accommodations

Please check all that apply:

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If you selected Alternative Testing Format, please specify:

If you selected Assistive Technology, please specify:

If you selected other academic or classroom accommodation, please specify:

Housing / Meal Accommodations

Please select all that apply:

If you selected other housing or meal accommodation, please specify:

Check this box indicating you understand

I understand that by selecting this box, I agree to authorize the Office of Accessibility Services at Shepherd University to release this information to the appropriate Shepherd University faculty and staff members in the coordination of my accommodations at Shepherd University.

Part V: Documentation

Upload supporting document(s)