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Request for Accommodations
Please use this form to begin the process of registering with the Accessibility office at Malone University.
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* Indicates required question
First semester enrolled at Malone?
*
Your answer
Current student level at Malone?
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Freshmen
Sophomore
Junior
Senior
Other:
Last Name
*
Your answer
First Name
*
Your answer
Address
*
Your answer
Student Cell Phone Number
*
Your answer
Malone 6 digit student ID (if known)
Your answer
Email Address:
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Major:
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Your answer
Previous high school or college attended:
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Your answer
Residential status
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Commute from home
Off- campus
Resident
Other:
Check all that apply to you:
*
ADHD
Autism Spectrum Disorder
Chronic Health Condition
Cognitive/Learning Disability
Deaf/Hearing Loss
Visual Impairment
Neurological condition
Psychological Disaiblity
Traumatic Brain Injury
Other:
Required
If you checked "other" above, please describe your situation:
Your answer
Describe how your disability affects you academically:
*
Your answer
Describe how your disability affects you socially:
*
Your answer
Are you taking medication for your disability? Please list below. (Please type N/A if none)
*
Your answer
What accommodations (if any) are you requesting for the classroom/testing? (Please type N/A if none)
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Your answer
What accommodations (if any) are you requesting to have for technology? (Please type N/A if none)
*
Your answer
What accommodations (if any) are you requesting for housing or dining? (Please type N/A if none)
*
Your answer
Are you interested in being assigned a Peer Mentor to meet with weekly to help with accountability, time management, organization, etc?
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No
Yes
Maybe
What other requests do you have? (Please type N/A if none)
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Your answer
I understand that submitting this form does not automatically qualify me for accommodations. I agree to provide appropriate documentation to the Director of Accessibility Services. I understand that no accommodations will be put in place until all the forms/documents are received by the Center for Student Success and an approval is given through an intake meeting with the Director of Accessibility.
Documents can be sent to Jen Tobias, jvannest@malone.edu.
More information regarding disability services can be found at here:
https://www.malone.edu/academics/academic-resources/center-for-student-success/accessibility-services-2/academic-accommodations/
My signature below states that I have been made aware of the process and my responsibilities. I agree that all information provided is true and accurate.
*
Your answer
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