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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.

______________________________________________________________________________________________________________

Application And Request For Accommodations And Services Form - Rockford University - Disability Support Services