- Vermont_StudentAccomodation

DISABILITY ACCOMMODATION REQUEST FORM

NOTE: Do not attempt to complete this form before carefully reading "How to Request an Accommodation for a Disability" If you have questions on this form, please contact VLGS's 504 Coordinator, Associate Dean Lisa Ryan at lryan@vermontlaw.edu.

1. Your Name: *

First Name *

Middle Name

Last Name *

2. Program Enrolled in or Applying to: *

3. Primary Site: *

4. Anticipated Graduation Year (if known):

5. Preferred Phone:

6. Preferred Address:

Street 1:

Street 2:

City:

State:

Zip:

7. Email: *
(Please note: All communication with current students will be conducted through your official VLS email address.)

8. Nature of your disability:
(check all that apply)

Physical

Psychological

Learning

ADHD

Vision

Hearing

Other :

9. If you have been diagnosed with a specific condition, please state it here:

10. Date of diagnosis(If known):

11. The health care professional who provided—or who will provide—required medical documentation pursuant to the Documentation Guidelines (available here) regarding my condition(s) and accommodations(s) is:
Health Care Professional:

12. Please upload all documentation required under the pertinent documentation guidelines.

(Documentation Guidelines available here)

If you are not uploading medical documentation at this time, please state the reason here (e.g. technical difficulties, documentation not yet obtained, not yet tested, you will hand-deliver or mail, etc.):

13. Accommodation(s) requested: (check all that apply)

Special exam answer format (e.g. computer only, handwritten only, large print, voice-to-text, etc.)

Additional time for in-class, timed exams

Private exam room

Special Seating Arrangements (e.g. sit/stand requirements, front row requirements, etc.)

Electronic texts and/or text-to-speech readers

Notetaker Services/Class Recordings

Wheelchair Accessibility

Other :

14. Past Accommodations

a. Did you receive formal accommodations while you were in college or in other recent academic setting? *

Yes No

b. Have you received accommodations for standardized tests such as the SAT, LSAT, GRE or GMAT? *

Yes No

c. Have you received accommodations at a place of employment? *

Yes No

d. If you answered "Yes" to any questions above, please describe and upload any relevant documentation:

Upload Document:

e. If you answered "No" to all questions above, please state why you are requesting accommodations today:

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