Accommodations Request

Accommodations Initial Contact Form

This is the official request form to initiate the process of securing academic and/or housing accommodations. Students (not parents or providers) should complete this Accommodations Initial Intake Form in its entirety. Once submitted, students will receive an email from the Accessible Education Coordinator indicating the acceptable forms of documentation of disability and next steps in the process. The accommodations request process is not considered complete until a student has submitted the appropriate documentation, met with the Accessible Education Coordinator, and received email notification of a decision. Approved accommodations will only be implemented after an Authorization of Accommodations Form is submitted.

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Student's Name:*
First Last
PC Student ID #:*
PC Email:*
Student's Cell Phone #:*
Student's Home Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
SECTION I. Types of Requested Accommodations
Please check all the accommodations you are requesting.
Types of Requested Accommodations*
- Academic
- Housing
- Meal Plan
- Physical Campus
SECTION II. Declared Disability
The Office for Civil Rights defines a person with a disability as, “a person with a physical or mental impairment that substantially limits a major life activity; has a record of such an impairment; or is regarded as having such an impairment. The determination of whether a student has a physical or mental impairment that substantially limits a major life activity (and therefore has a disability) must be made on a case by case basis.”
Select all that apply.
Select all that apply.
- 󠄀 Attention Deficit/Hyperactivity Disorder (ADD/ADHD)
- Autism Spectrum Condition/Disorder
- Chronic Medical Condition
- Deaf or Hard of Hearing
- Learning Disability
- Physical/Mobility
- Psychological
- Visual Impairment
SECTION III. Accommodation Requests
Select the reasonable academic accommodations that you believe will provide you with equal access to education, housing, meal, or co-curricular activities at PC. (Equal access is defined by the U.S. Department of Education as an equal opportunity of a qualified person with a disability to participate in or benefit from educational aid, benefits, or services.). Indication of these accommodations does not necessarily mean these are the accommodations you will receive.
ACADEMICS:
Select all that apply.
- Extra time on in-class tests, quizzes, and labs
- Testing in a separate or distraction-reduced room
- Priority seating in classroom in front row, near the front, or with easy access to exit
- Copies of lecture notes or access to PowerPoints or other visual aids, if not provided already to all students
- Use of electronic device for note-taking (ex: laptop, iPad, digital recorder, SmartPen, etc.) *these devices will be provided by the student
- Frequent breaks, as needed during class or lab
- Attendance flexibility due to medical condition. Generally, instructors clearly state essential course requirements and the course attendance policy on their syllabi. Instructors are neither expected to compromise the essential course requirements nor to fundamentally alter the course regardless of the student’s medical condition.
- Permission to record class lecture only for personal study purposes. Information in audio-recorded lectures is protected under federal copyright laws and may not be published, quoted, or shared with others without the express consent of the lecturer. Any other use will be considered a violation against the Honor Code.
- Extra travel time to and between classes for mobility support
- Closed-captioned videos
- E-books or alternative format textbook (Assistance securing these with publishers)
- American Sign Language Interpreter
- Captionist or Scribe
- Other
If "Other" was selected, please describe:
HOUSING/MEALS:
Select all that apply.
- Single Room
- Single room with private bathroom
  
  (Single rooms are determined on a case-by-case basis and limited by room space availability). Students with disabilities or medical conditions are assigned roommates in the same manner as other housing applicants unless the need for a single room is identified as a reasonable accommodation or medical necessity and one is available at the time the student’s housing application is processed. It is recommended that students submit the Accommodations Initial Intake Form and appropriate medical documentation as soon as possible to ensure a proper room accommodation).
- ADA accessible room (including bathroom)
- First-floor room
- Emotional Support Animal (Emotional Support, Comfort, Companionship, or Therapy animal)
- Service Animal (The Department of Justice (“DOJ”) and the ADA define a “service animal” as “any dog that is individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability”. The DOJ is explicit that emotional support, comfort, or companionship animals are not considered service animals under the ADA.
- Dietary restriction(s) or Food Allergies
- Other
  NOTE: Returning students who need this accommodation for a future semester or school year MUST submit an Authorization of Accommodations Form prior to the priority housing application deadline as set by the Office of Residence Life. The Academic Success Office will then notify Residence Life of this request.
If "Other" was selected, please describe:
SECTION IV. Outside Agency Support
Select any of the following outside agencies from which you are currently receiving support.
OUTSIDE AGENCY SUPPORT:
Select any of the following outside agencies from which you are currently receiving support.
- Vocational Rehabiliation
- Services for the Deaf and Hard of Hearing
- VA
- Other
- Not applicable
If "Other" was selected, please describe:
SECTION V. Signature
Disability-related information is protected by the Buckley Amendment. Information will not be released or discussed without student’s expressed written consent except to College officials and faculty having legitimate educational interests and on a need-to-know basis. Students, by submitting this Accommodations Initial Intake Form, you are providing your electronic signature consent for the Accessible Education Office to share this information with College officials and faculty, as stated.
I understand that my electronic signature affirms that I am registering with the С��Ƶ Accessible Education Office as a student with a documented disability as defined by the Americans with Disabilities Amendments Act and Section 504 of the Rehabilitation Act. I understand that despite my disability,
1. I must meet the minimum standards as set forth by my program of study, with or without accommodations, keeping in mind that instructors are neither expected to compromise the essential course requirements nor to fundamentally alter a course.
2. I am responsible for following С��Ƶ’s policies as outlined in the Arts and Sciences Academic Catalog, The Garnet Book, and the Blue Book.
3. I must complete and submit an Authorization of Accommodations Form to the Accessible Education Office for each semester that I am enrolled and intend to receive the approved accommodations. Doing so provides the Accessible Education Office permission to provide my Accommodations Approval Form to my professors and/or Office of Residence Life. (This is not automatically done for me.) Instructors are not responsible for implementing immediate accommodations when students wait until the last minute to complete their Authorization of Accommodations Form.
4. It is my responsibility to discuss my approved accommodations with each of my instructors.
5. In addition to this form, diagnostic documentation from a healthcare provider must be received in order for my file to be reviewed for accommodations.
6. I understand that I must participate in the structured exchange process with the Accessible Education Coordinator
Student's E-Signature:*
Today's Date*
mm/dd/yyyy
MM slash DD slash YYYY

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