APPLICATION FOR STUDENT ACCOMMODATIONSSECTION 1: STUDENT’S INFORMATION
Student’s Name:

Campus Name:

Banner (U) Number:
Address:
Email Address:
Gender:MaleFemale

Date of Birth:
Student’s Phone #:Other:

Semester Accommodations Being Requested:

Prefer Not to Answer
Fall

SpringSummer, 20Classification:Freshman
Sophomore
JuniorSeniorDual Enrollment
Non-Degree Student
For SULC Students Only:
1L
2L
3L
4L

Graduate Student

Major:
Student Organization(s):Residency:
In-state student that lives on-campus
Out-of-state student that lives on-campus
Do you receive third-party billing:Yes
If yes, list third-party vendor:

In state student that lives off-campus
Out-of-state student that lives off-campusNo

Are you a client of Louisiana Rehabilitation Services:
If yes, list case manager:

Yes

No

Are you residing in residential housing:YesNo
If yes, are you requesting an emotional support animal:Yes

Are you a veteran:

Yes

No

No

Did you receive accommodations through Disability Services last semester:
SECTION 2: EMERGENCY CONTACT
Name:

Relationship:

Email:

Phone #:

Page 1 of 4Yes

NoDo you grant Disability Services permission to speak with your emergency contact regarding yourrecords, including any accommodations, housed within Disability Services? This is a waiver ofyour rights under the Family Educational Rights and Privacy Act (FERPA).
YesNo
SECTION 3: NATURE OF REQUESTDisability
Temporary Disability
English-Second Language (ESL)
Pregnant and Parenting
SECTION 4: NATURE OF DISABILITY
Please indicate your disability type(s). Check all that apply.
Sensory Disability (e.g., hearing impairment, visual impairment, etc.)
Learning Disability
Physical/Medical Disability
Psychological/Mental Health Disability
Attention Deficit Hyperactivity Disorder (ADHD)
Other:
Please describe your diagnosed disability(ies), and state your date of most recent diagnosis.

Please describe how your disability affects you both outside and inside the classroom, including
testing and studying situations.

List the names and contact information of the medical professional(s) treating the disabilities statedin this application.

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SECTION 5: ACCOMMODATIONSCheck all the accommodations you are requesting.
Accessible Classroom/Location/Furniture
Alternative Format Material
Assignment Extension Accommodations
Assistive Technology
Attendance Accommodations
CaptioningCourse Substitution
Extended Time for Exams
Interpreting Services
Recording Lectures
Testing Location
Other:
List any accommodations previously received.

SECTION 6: STUDENT RESPONSIBLITIESAs the Student, I understand the following:
1. Accommodations are not retroactive, and the University is not obligated to provide
accommodations until the application process has been completed and accommodations
have been officially approved by the Disability Services Coordinator.
2. It is my responsibility to self-disclose the presence of a disability to Disability Services tobe eligible for accommodations through Disability Services.
3. It is my responsibility to request accommodations from Disability Services in advance ofthe need each semester.
4. It is my responsibility to self-advocate and communicate with faculty and staff as it relates
to my disability and accommodations. This includes meeting with my professors to discuss
the accommodations for each course.
5. It is my responsibility to routinely check my University email.

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6. It is my responsibility to participate in the intake appointment with the Disability Services
Coordinator after submitting this application.
7. It is my responsibility to follow the procedures for requesting and accessing specificaccommodations.
8. It is my responsibility to meet the same essential standards as students without disabilities
in my academic program and courses. Essential standards include academic, behavioral,performance, and technical standards.
9. It is my responsibility to report any challenges related to approved accommodations to theDisability Services Coordinator or ADA Coordinator as soon as is reasonably possible toaddress the challenge and avoid delays in accessing the accommodations.
10. It is my responsibility to follow all policies and procedures relating to Disability Services.
11. Each semester in which I am requesting accommodations through Disability Services, I
must submit the following to Disability Services:a. Application for Accommodations,b. Complete course schedule, andc. Paid fee bill.
12. If I qualify for testing in the Disability Services testing center, it is my responsibility toschedule the exam at least three (3) business days prior to the exam with the Disability
Services Coordinator and my professor.
13. If I qualify for the accommodation of recording lectures, I understand that I may not share
the recorded lecture with other people without consent from the lecturer. I further
understand that I shall no longer be eligible for this accommodation if I have been foundto have shared a recorded lecture without the lecturer’s consent.
14. If I check out any equipment from Disability Services, it is my responsibility to ensure theequipment is neither lost, damaged, nor unreturned. I will be responsible for the current
replacement or repair cost, which will be reflected on my student financial account.
SECTION 7: STATEMENT OF CONFIDENTIALITYThe Southern University System is committed to ensuring that all information and communication
pertaining to a student’s disability is maintained as confidential as required by law. Therefore, all
documentation obtained as part of an accommodation request, including medical and other relevant
information, shall be maintained as confidential records, separate from the student’s academic
record, and subject to disclosure only as allowed by law or with the student’s permission.
SECTION 8: SUPPORTING DOCUMENTATION
Please provide any supporting documentation for your request with this application. If additional
documentation is needed, Disability Services will contact you.
Please note that any medical documentation, testing, evaluations, assessments, etc. must be within
three (3) years of the start of the semester in which you are applying for accommodations.
Student’s Signature:

Date:

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