Looking for a Application Form Templates? Download it for free!

Academic History Continued

2. Did you attend a  public OR  private high school? Name of school: _______________________________________________

Are you transferring to RU from another college or university?  No  Yes - Name of school: _____________________________

3. Did you have an IEP, 504 Plan or some other school-based support?  No  Yes - If so, please submit a copy or verification

letter with this form.

4. What were your grades or GPA in high school or any other undergraduate studies?

______________________________________________________________________________________________________________

5. Are you taking any medication or have you participated in any therapeutic services (therapy, coaching, support services, etc.) to

manage your condition? If so, please describe whether these were effective or ineffective.

______________________________________________________________________________________________________________

6. Approximately how many hours a week do you spend studying/preparing for school?

______________________________________________________________________________________________________________

7. Do you feel you will need additional support services (assistance with reading, writing, study skills, time management/ organization,

self advocacy skills or informal academic advising, etc.)?

______________________________________________________________________________________________________________

Informed Consent for Information Release

I, ______________________________________________, hereby authorize Disability Support Services at Rockford University

to discuss, either in writing, electronically, including e-mail, or orally, my academic adjustments or accommodations

with appropriate administrators, instructors, professors, and third-party service providers as deemed necessary by RU

Disability Support Services staff for the purpose of providing and/or coordinating accommodations and services for

me.

Signature: ______________________________________________ Date: _____________________________________

Date of Expiration:________________________________________

(If no date is listed, this release will remain in effect while you are a student attending Rockford College)

Your request for services and accommodations must be submitted with formal documentation. Documentation must be from a

licensed provider and be within the last three years.

Both documentation and this request must be received before

accommodations can be implemented.

Please submit this form to our office via mail, fax, email, or in person:

Lang Center for Health, Wellness, Counseling, and Disability Support Services

Rockford University | 5050 E. State St. | Rockford, IL 61108

Phone: (815) 226-4083 Fax: (815) 226-3335 Email: healthcenter@rockford.edu

Application And Request For Accommodations And Services Form - Rockford University - Disability Support Services Page 2