Rockford University - Disability Support Services
Application and Request for Accommodations and Services (to be completed by student)
Name: _________________________________________________________________ Date: _____________________________
PC ID: _________________________________ Date of Birth: ____________________ Phone: ____________________________
RU Email: _________________________________ @rockford.edu Other Email: ________________________________________
Major: ____________________________________________________________________________________________________
Are you a client of the Division of Vocational Rehabilitation? No Yes - If yes, please list your DVR counselor's
name and phone number:_____________________________________________________________________________________
Disability and Current Impact
In addition to reviewing your documentation, your answers to the following questions will assist us in understanding the current impact
of your disability.
1. What is your disability? ________________________________________________________________________________________
2. Describe how your disability is currently impacting you in:
a.) School: _____________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
b.) Work: _________________________________________________________________________________________ ___________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
c.) Social/Personal: _________________________________________________________________________________ ___________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
3. What accommodations are you requesting? (Include academic, physical, communication access needs)
Accommodation
Reason
_________________________________________________
___________________________________________________
_________________________________________________
___________________________________________________
_________________________________________________
___________________________________________________
_________________________________________________
___________________________________________________
Academic History
1. Describe your strengths, weaknesses, and special interests.
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________