WASHINGTON AND LEE UNIVERSITY

Request For Accommodation of Disability

Name:  ________________________________________________________________

Date:  __________________   E-Mail Address: _______________________________

School Address: ________________________________  Phone: __________________

Home Address: _________________________________ Phone: __________________

Describe your disability. ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe past accommodations granted for your disability:

a.          Did you receive any accommodations in high school or at any other college?

            Yes ____No _____.  If yes, please explain and provide a letter from your high school or other undergraduate college on its official letterhead. __________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________

b.          Were you granted any accommodations for taking the SAT, ACT, or TOEFL examinations? 

            Yes _____No _____.  If yes, please specify which test you took and describe the accommodations you were given.  __________________________________________________________________________________________________________________________________________________________________________

What accommodations are you requesting? _______________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

I authorize and request the Associate Dean of the College for Student Academic Support (“Associate Dean”) to consider this request for accommodations and copies of all documentation provided in connection with this request and, only as he/she deem(s) necessary for the evaluation of my eligibility/accommodation, to consult with other educational, medical, or psychological professionals, disclosing such information as he/she/they deem(s) relevant for consultation.  I consent to the Associate Dean discussing this request and all evaluations and assessments pertinent to my disability with any diagnosing/evaluating professionals.

Requesting Student’s Signature ______________________________  Date ___________

NOTE:  This request cannot be acted upon until you provide sufficient documentation of disability as required by both the Office of the Dean of the College and University guidelines.  Students need to submit a request for accommodation at the start of each academic year, unless the Dean determines otherwise.