Disability Accommodation Request

Student Disability Services

The Office of Student Disability Services supports students with disabilities at Marywood University. If you are a student with a disability and would like to request accommodations, please complete the form below. Please note that you will be asked to attach documentation to support your request. Please review the Documentation Guidelines to ensure you provide sufficient information to process your request. We coordinate appropriate accommodations based on documentation provided by the student and relevant professionals. We will review the information in this request and supporting documentation and then we will contact you via your Marywood email regarding next steps.

First NameRequired *

Last NameRequired *

Middle Name

Student IDRequired *

EmailRequired *

Please use your university issued email address

Phone NumberRequired *

Current Class Level

Disability Information

What is your diagnosis?Required *

ADHD, Learning Disability, Anxiety Disorder, etc.

Tell us more about your diagnosis and how it affects youRequired *

What symptoms currently affect you? How have you coped? What is your biggest struggle?

Accommodation Information

I am requesting academic accommodations.

I am requesting academic accommodations. Yes I am requesting academic accommodations. No

How does your disability affect you in the classroom?

Concentration, listening, notes, hearing, vision, etc.

How does your disability affect you during tests?

Timed exams, presentations, test formats, etc.

How does your disability affect you outside the classroom?

Homework, study, organization, papers, time management, etc.

How does your disability affect your daily living?

Sleep, allergies, involvement on campus, sports, clubs, etc.

What academic accommodation(s) are you requesting?Required *

Have you previously used accommodations?Required *

Have you previously used accommodations? Yes Have you previously used accommodations? No

Please describe your previous accommodationsRequired *

I am requesting housing accommodations.Required *

I am requesting housing accommodations. Yes I am requesting housing accommodations. No

Information Regarding RequestRequired *

Marywood University provides accommodations for students with disabilities in order to facilitate full participation and access to university housing. Please keep in mind that we meet reasonable accommodation needs. You will not necessarily receive your housing preference. If you are not happy with your room assignment given to meet your accommodation needs, you are encouraged to decline the placement and go through the general housing selection process.

Information AcknowledgementRequired *

Do you acknowledge that you have read and understand all of the information listed above?

Information Acknowledgement Yes Information Acknowledgement No

I am requesting an ESARequired *

I am requesting an ESA Yes I am requesting an ESA No

What housing accommodations are you requesting?

Please describe the room configuration required and specific housing accommodations required for equal access

Have you had a housing accommodation in prior semesters at Marywood?Required *

Have you had a housing accommodation in prior semesters at Marywood? Yes Have you had a housing accommodation in prior semesters at Marywood? No Have you had a housing accommodation in prior semesters at Marywood? Unsure

If you have not had housing accommodations prior please explain what has changed that you now require accommodations.Required *

Provider Information and Release

To evaluate requests based on medical, psychological, or any disability-related conditions accurately and equitably, Marywood will need sufficient information to understand how the requested housing assignment relates to and impacts any and all current conditions. For those conditions, such documentation generally consists of an evaluation and recommendation by an appropriate professional providing treatment for the condition.
A prescription form, brief description, or brief memo/letter is not sufficient information for our review process. Documentation supporting a request will be reviewed by the Office of Student Disability Services and is considered confidential. Additionally, submission of documentation does not guarantee that a specific housing accommodation will be provided.Please note, submission of this information, in addition to supporting documentation, does not guarantee that a specific accommodation will be granted. Each request is considered on a case-by-case basis.

Provider Release/Acknowledgement - Do you acknowledge that you have read and understand all of the information listed above?Required *

Provider Release/Acknowledgement - Do you acknowledge that you have read and understand all of the information listed above? Yes Provider Release/Acknowledgement - Do you acknowledge that you have read and understand all of the information listed above? No

Upload supporting document(s)

Please attach documentation of your disability (IEP, 504 Plan, medical or mental health documentation containing your diagnosis/accommodation recommendations). Please review the Documentation Guidelines to ensure you provide sufficient information to process your request.

Acknowledgement of InformationRequired *

By typing my full legal name below I am acknowledging that I have read and I understand the information on this form. This shall act as my electronic signature and I, as the student, have completed this form myself. Also, all of the information provided is accurate to the best of my knowledge.

Disability Accommodation Request

Student Disability Services

Disability Information

Accommodation Information

Document Information