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Public Accommodation Request
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Public Accommodation Request
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Student Information
Please enter your information
First Name
*
:
Last Name
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:
Middle Name
:
WIN (Western Identification Number)
*
:
Birthday
*
:
January
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Email
*
:
Please use your university issued email address
Cell Phone Number
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:
Military Status
:
Are you active military or a veteran?
Military Status
yes
Military Status
no
Please identify the branch of service and status
:
Service Agencies
:
Are you a client or receiving services from any State or Federal Agency?
Service Agencies
yes
Service Agencies
no
List all agencies
:
Disability Information
Instructions: There is much variability within each disability category, and therefore, the type of accommodations needed can vary significantly. Below, you will find descriptions of the various types of disabilities recognized in the United States. Student needs vary according to each individual. Therefore, it is important for the participating student to clarify the particular disability.
My diagnosed disability falls into the following category
*
:
You may select as many disabilities with which you identify
[select]
[select]
clear
How does your disability affect you academically?
*
:
What accommodations are you requesting?
*
:
What accommodations are you requesting?
Accommodation
Have you received accommodations in the past?
*
Have you received accommodations in the past?
yes
Have you received accommodations in the past?
no
The date I would need this accommodation is
January
February
March
April
May
June
July
August
September
October
November
December
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
Accommodation
Please list all accommodations you have received at other institutions or schools
Upload supporting document(s)
:
If you have documentation, such as IEP, 504 plan, medical information, psychological evaluation or other information concerning you disability, please upload it now.
Abdominal Migraines
Acute Lymphoblastic Leukemia
ADD/ADHD - Other
Allergies/Anaphylaxis
Anorexia
Anxiety Disorder
Aphasia
Arthritis
Asperger's Syndrome
Asthma
Attention Deficit/Hyperactivity
Auditory Processing
Autism Spectrum Disorder
Balance
Bi-polar
Bilateral Hearing Loss
Blind
Blindness/Low Vision
Brain Cancer
Broad Written Language
Bulimia
Cancer
Carpal Tunnel disease
Cataplexy
Celiac Disease
Cerebral Palsy
Cervical Fusion
CHARGE
Chest Pain
Chronic Fatigue
Chronic Health
Chronic Illness - Other
Chronic Pain
Cochlear Implants
Cognitive
Cognitive Processing
Communication
Concussion
Crohns/Colitis/IBS
Cyclothymia
Cystic Fibrosis
Depression
Developmental Coord. Disorder
Dexterity Issues
Diabetes
Diabetic Retinopathy
Dyscalculia/Mathematics
Dysgraphia
Dyslexia
Dysthymia
Ehlers-Danlos Syndrome
Emotional/Psych - Other
Epidermolysis Bullosa
Epilepsy/Seizure Disorder
Executive Functioning
Gastric Issues
Gastroparesis
Generalized Anxiety Disorder
Hearing
Hearing Aids
Hearing Impairment - Other
Hip Replacement
hydradenitis Supprativa
Hypertrophic cardiomyopathy
Immune Deficiency
Information Processing Deficit
Laminectomy Lumbar
Learning
Learning Disability - Other
Low Hearing
Low Vision
Lupus
Macromastia
Mast Cell Activation Syndrome
Medical Conditions
Medical Disability - Other
Memory/Retention Issues
Metastatic Sarcoma
Migraines
Mobility
Mobility Impairment - Other
Mood Disorder
Multiple Sclerosis
Muscular Dystrophy
Neurofibromatosis
Neurologic Bladder Disorder
Nonverbal Language Disorder
Nystagmus (vision)
Obesity
OCD
Orthostasis
Osteoarthritis
Other
Panic Attacks
Polycystic Ovary Disease
POTS
Processing Speed
Psychological
PTSD
Reading Comprehension
Receptive Language Deficit
Reconstructive Ear Surgery
Reduced (One Ear)
Reflex Sympathetic Dystrophy
Retinal Scars
Retinitus Pigmentosos
Schitzoid-affective disorder
Schizophrenia
Sciatica
Scoliosis
Sensorineural Hearing Loss
Severe Low Vision
Sit/Stand Issues
Sleep Apnea/Narcolepsy
Speech Impairment
Stargardt Disease
Syncope
TBI from Car Accident
TBI/Other
Temporary
Tethered Spinal Cord
Tetralogy of Fallot
Tourettes Syndrome
Traumatic Brain Injury
Unsteady Gait
Visual Impairments - Other
Word Recognition
Written Expression
Abdominal Migraines
Acute Lymphoblastic Leukemia
ADD/ADHD - Other
Allergies/Anaphylaxis
Anorexia
Anxiety Disorder
Aphasia
Arthritis
Asperger's Syndrome
Asthma
Attention Deficit/Hyperactivity
Auditory Processing
Autism Spectrum Disorder
Balance
Bi-polar
Bilateral Hearing Loss
Blind
Blindness/Low Vision
Brain Cancer
Broad Written Language
Bulimia
Cancer
Carpal Tunnel disease
Cataplexy
Celiac Disease
Cerebral Palsy
Cervical Fusion
CHARGE
Chest Pain
Chronic Fatigue
Chronic Health
Chronic Illness - Other
Chronic Pain
Cochlear Implants
Cognitive
Cognitive Processing
Communication
Concussion
Crohns/Colitis/IBS
Cyclothymia
Cystic Fibrosis
Depression
Developmental Coord. Disorder
Dexterity Issues
Diabetes
Diabetic Retinopathy
Dyscalculia/Mathematics
Dysgraphia
Dyslexia
Dysthymia
Ehlers-Danlos Syndrome
Emotional/Psych - Other
Epidermolysis Bullosa
Epilepsy/Seizure Disorder
Executive Functioning
Gastric Issues
Gastroparesis
Generalized Anxiety Disorder
Hearing
Hearing Aids
Hearing Impairment - Other
Hip Replacement
hydradenitis Supprativa
Hypertrophic cardiomyopathy
Immune Deficiency
Information Processing Deficit
Laminectomy Lumbar
Learning
Learning Disability - Other
Low Hearing
Low Vision
Lupus
Macromastia
Mast Cell Activation Syndrome
Medical Conditions
Medical Disability - Other
Memory/Retention Issues
Metastatic Sarcoma
Migraines
Mobility
Mobility Impairment - Other
Mood Disorder
Multiple Sclerosis
Muscular Dystrophy
Neurofibromatosis
Neurologic Bladder Disorder
Nonverbal Language Disorder
Nystagmus (vision)
Obesity
OCD
Orthostasis
Osteoarthritis
Other
Panic Attacks
Polycystic Ovary Disease
POTS
Processing Speed
Psychological
PTSD
Reading Comprehension
Receptive Language Deficit
Reconstructive Ear Surgery
Reduced (One Ear)
Reflex Sympathetic Dystrophy
Retinal Scars
Retinitus Pigmentosos
Schitzoid-affective disorder
Schizophrenia
Sciatica
Scoliosis
Sensorineural Hearing Loss
Severe Low Vision
Sit/Stand Issues
Sleep Apnea/Narcolepsy
Speech Impairment
Stargardt Disease
Syncope
TBI from Car Accident
TBI/Other
Temporary
Tethered Spinal Cord
Tetralogy of Fallot
Tourettes Syndrome
Traumatic Brain Injury
Unsteady Gait
Visual Impairments - Other
Word Recognition
Written Expression
