Academic Accommodation Registration

Academic Accommodation Registration
Disability Support Services (DSS) Mission Statement
Saint Mary-of-the-Woods College is committed to providing reasonable and appropriate accommodations to students with documented disabilities in order to afford them an equal opportunity to participate in college programs, courses and activities. All accommodation requests come to the Disability Support Services (DSS) office housed under the Learning Resource Center.
Disability Documentation Guidelines
Student requesting academic accommodations must provide documentation from a qualified treating professional confirming a diagnosis of a disability.

Documentation can include any one or more of the following:
- Letter from a current professional in psychological or medical treatment (i.e. Physician, Psychologist, licensed therapist, nurse practitioner, etc.) confirming disability
- Previous 504 Plan or IEP from high school
- Accommodation documentation from a previous institution of higher education
- Diagnostic Testing Results
Disability Support Services Intake Form
All information provided on this form will help us to ensure that our students have the appropriate accommodations to grant equal access to academic success at Saint Mary-of-the-Woods College. Please complete questions with as much detail as possible.
Name*

First NameLast Name
Which of the following pronouns do you prefer to use?

They/ThemShe/HerHe/HimZe/HirNo PreferenceNone (just use my name only)Other
Student ID Number
SMWC Email*
example@smwc.edu
Date of Birth *

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Current Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Student Standing *
Provider Information

Please include as much contact information as possible regarding your current licensed treatment specialist. This could include your primary care physician, therapist, psychiatrist, or other licensed clinical practitioner. It may be necessary to collect additional information in order to provide you with the most comprehensive accommodations.
Name*

First NameLast Name
Provider Title/Certification (Medical Doctor, Licensed Clinical Social Worker [LCSW], Therapist, etc...)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number (recommended)
Please enter a valid fax number.
Email (Optional)
example@example.com
Length of Time Under Care (2 years, etc...)*
Date of Most Recent Evaluation/Consultation*
Do you need to add an additional provider or licensed professional providing care in your treatment?

YesNo
Name*

First NameLast Name
Provider Title/Certification (Medical Doctor, Therapist, LCSW, etc.)*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number (recommended)
Please enter a valid fax number.
Email (Optional)
example@example.com
Length of Time Under Care (2 years, etc...)*
Date of Most Recent Evaluation/Consultation*
Disability Information
The Fair Housing Act, Americans with Disabilites and Rehabilitiation Act defines a person with a disability as a person who has a physical or mental impairment that substantially limits one or more major life activity.
Type of Disability (Diagnosis) *
Ex. Visually Impaired, Specific Learning Disability, Psychological Disorders, Attention Deficit Hyperactivity Disorder (ADHD), Mobility, Deaf/Hard of Hearing, Chronic Medical Condition, Traumatic Brain Injury (TBI)
Have you been evaluated for a learning disability in high school (e.g., 504 plan or IEP) or received an accommodation at another college? *
What accommodations, if any, have you used previously? *
Do you need to discuss your options with an ADA advisor for Saint Mary-of-the-Woods College?

YesNo
Please list any and all accommodations that you would like to discuss/possibly need?*
Extended time for tests, note-taker, calculator, etc...
Upload Supporting Document(s): Letter from a current professional in healthcare (e.g., primary care physician, psychologist, therapist, nurse practitioner, etc...) confirming disability, a previous IEP or accommodation documentation, 504 plan, diagnostic testing results.

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Statement of Confidentiality
The staff in Disability Support Services (DSS) will keep all academic and disability related information confidential, except when given permission by the student to share said information. However, DSS staff are required to disclose information when an individual presents a danger to self or others, when subpoenaed for records or testimony in courts, or due to a need-to-know basis by university officials. Student Initialshave read the above Statement of Confidentiality and fully understand its terms and conditions.
The information contained in this form is true and accurate to the best of my knowledge. Signature:

Clear
Date

MonthDayYear
Date
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Academic Accommodation Registration

Disability Support Services (DSS) Mission Statement

Disability Documentation Guidelines

Disability Support Services Intake Form

Provider Information

Disability Information

Statement of Confidentiality