Disability Services | Request Accommodations | Disability Services Request Form

Disability Services Request Form

All information provided to the Disability Services Office is kept confidential and will only be shared with your permission with individuals directly involved in providing approved accommodations.

(* Required)

Personal Information
Date	7/24/08
Student Name *
Student ID
Date of Birth *	/ /

Local Address
City/State/Zip	,
Students living in RIT housing: Do you require evacuation assistance? *	Yes No

Permanent Address *
City/State/Zip *	,

Local Phone
Permanent Phone *
Cell Phone
E-mail *
Academic Information
College at RIT *
Major *
Status *
Enrollment quarter and year (New or transfer students: Enter your expected enrollment quarter) *
Disability
What is/are your disabilities? *
If you are requesting academic accommodation(s)...
Please describe how your disability impacts your learning.
Please list and describe the academic accommodation(s) you are requesting.
If you are requesting accommodations in your dietary or housing arrangements...
Please explain the difficulties you experience with residential living as well as the accommodation(s) you are requesting.

I will submit documentation of my disability separately as mentioned in the documentation guideline. *