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Public Accommodation Request
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Student Information
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First Name
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Preferred Name
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WMU Preferred name
processes to use a preferred name at the University.
Last Name
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Middle Name
WIN (Western Identification Number)
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Birthday
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Month
January
February
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April
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Day
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Year
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2023
2024
WMU Email
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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
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You may select as many disabilities with which you identify
ADD/ADHD
Autism Spectrum Disorder
Autism Spectrum Disorder: Asperger's Syndrome
Autism Spectrum Disorder: Autism Spectrum Disorder
Blind/Low Vision
Blind/Low Vision: Blind
Blind/Low Vision: Blindness/Low Vision
Blind/Low Vision: Low Vision
Blind/Low Vision: Nystagmus
Blind/Low Vision: Retinal Scars
Blind/Low Vision: Retinitis Pigmentosos
Blind/Low Vision: Severe Low Vision
Blind/Low Vision: Stargardt Disease
Blind/Low Vision: Visual Impairments- Other
Deaf/Hard of Hearing
Deaf/Hard of Hearing: Bilaterial Hearing Loss
Deaf/Hard of Hearing: Cochlear Implants
Deaf/Hard of Hearing: Hearing
Deaf/Hard of Hearing: Hearing Aids
Deaf/Hard of Hearing: Hearing Impairment- Other
Deaf/Hard of Hearing: Low Hearing
Deaf/Hard of Hearing: Reduced (One Ear)
Deaf/Hard of Hearing: Sensorineural Hearing Loss
Learning Disability
Learning Disability: Auditory Processing
Learning Disability: Broad Written Language
Learning Disability: Cognitive
Learning Disability: Cognitive Processing
Learning Disability: Communication
Learning Disability: Dyscalculia/Mathematics
Learning Disability: Dysgraphia
Learning Disability: Dyslexia
Learning Disability: Executive Functioning
Learning Disability: Information Processing Deficit
Learning Disability: Learning
Learning Disability: Learning Disability- Other
Learning Disability: Memory/Retention Issues
Learning Disability: Nonverbal Language Disorder
Learning Disability: Processing Speed
Learning Disability: Reading Comprehension
Learning Disability: Receptive Language Deficit
Learning Disability: Word Recognition
Learning Disability: Written Expression
Medical
Medical: Abdominal Migraines
Medical: Acute Lymphoblastic Leukemia
Medical: Allergies/Anaphylaxis
Medical: Anorexia
Medical: Aphasia
Medical: Arthritis
Medical: Asthma
Medical: Brain Cancer
Medical: Bulimia
Medical: CHARGE
Medical: Cancer
Medical: Carpal Tunnel Disease
Medical: Cataplexy
Medical: Celiac Disease
Medical: Cerebral Palsy
Medical: Cervical Fusion
Medical: Chest Pain
Medical: Chronic Fatigue
Medical: Chronic Health
Medical: Chronic Illness- Other
Medical: Chronic Pain
Medical: Crohns/Colitis/IBS
Medical: Cystic Fibrosis
Medical: Diabetes
Medical: Diabetic Retinopathy
Medical: Ehlers-Danlos Syndrome
Medical: Epidermolysis Bullosa
Medical: Epilepsy/Seizure Disorder
Medical: Gastric Issues
Medical: Gastroparesis
Medical: Hydradenitis Supprativa
Medical: Hypertrophic Cardiomyopathy
Medical: Immune Deficiency
Medical: Lupus
Medical: Macromastia
Medical: Mast Cell Activation Syndrome
Medical: Medical Conditions
Medical: Medical Disability- Other
Medical: Metastatic Sarcoma
Medical: Migraines
Medical: Multiple Sclerosis
Medical: Muscular Dystrophy
Medical: Neurofibromatosis
Medical: Neurologic Bladder Disorder
Medical: Obesity
Medical: Orthostasis
Medical: Osteoarthritis
Medical: POTS
Medical: Polycystic Ovary Disease
Medical: Reflex Sympathetic Dystrophy
Medical: Sciatica
Medical: Scoliosis
Medical: Sleep Apnea/Narcolepsy
Medical: Speech Impairment
Medical: Syncope
Medical: Tethered Spinal Cord
Medical: Tetralogy of Fallot
Medical: Tourette's Syndrome
Medical: Traumatic Brain Injury
Mobility
Mobility: Balance
Mobility: Developmental Coord. Disorder
Mobility: Dexterity Issues
Mobility: Mobility Impairment- Other
Mobility: Sit/Stand Issues
Mobility: Unsteady Gait
Other
Psychological/Mental Health
Psychological/Mental Health: Anxiety Disorder
Psychological/Mental Health: Bipolar
Psychological/Mental Health: Cyclothymia
Psychological/Mental Health: Depression
Psychological/Mental Health: Dysthymia
Psychological/Mental Health: Generalized Anxiety Disorder
Psychological/Mental Health: Mood Disorder
Psychological/Mental Health: OCD
Psychological/Mental Health: PTSD
Psychological/Mental Health: Panic Attacks
Psychological/Mental Health: Psychological- Other
Psychological/Mental Health: Schizo- Affective Disorder
Psychological/Mental Health: Schizophrenia
Temporary
Temporary: Concussion
Temporary: Hip Replacement
Temporary: Laminectomy Lumbar
Temporary: Reconstructive Ear Surgery
Temporary: Temporary Other
Do you use assistive technology?
Required
*
Do you use assistive technology?
Yes
Do you use assistive technology?
No
What assistive technology do you use?
How does your disability affect you academically?
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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.
Document Information
Document Title
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File
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Maximum file size: 10240kb
Description