Disability Services Application

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CEDARVILLE UNIVERSITY DISABILITY SERVICES

By completing this application, you are verifying that you are a current or accepted, incoming student of Cedarville University with a diagnosed disability and are requesting academic accommodations because of the impact of your disability.

PROFESSIONAL DOCUMENTATION that evaluates your disability is required and may be submitted with this application. You will find the documentation requirements here.

TEMPORARY ACCOMMODATIONS: If you have been diagnosed with a temporary injury such as a concussion, please complete SECTION I only.

PERMANENT DISABILITY ACCOMMODATIONS: If you have a permanent disability diagnosis for which you require accommodations, please complete SECTIONS I AND II.

Section I: STUDENT PROFILE

First Name

Last Name

Middle Name

Address

Birth Date

7-Digit Cedarville Student ID#

ID Number Hint: Locate the number on your ID card. Count back 8 digits from the end of the number and eliminate the last digit. This is your 7-digit ID#.

Cedarville E-Mail Address:

E-mail address must be accurate. Please use your Cedarville.edu e-mail address if it has been assigned to you (username@cedarville.edu)

Cell Phone Number

I am requesting accommodations to begin:

Please identify the first semester in which you are requesting accommodations.

What will your classification be when accommodations begin?

Diagnosis/diagnoses:

If other, please identify specific diagnosis

Describe the symptoms and limitations you experience related to your diagnosis.

CONCUSSIONS OR TEMPORARY CONDITIONS: If you are requesting temporary accommodations, please give the date and the circumstances of your injury.

List current medications or treatments and any side effects that impact your academic performance.

Upload Supporting Documentation

For specific documentation requirements, go to www.cedarville.edu/disabilities, select ACCOMMODATION REQUESTS from the menu.

Section II: ACCESSIBILITY ACCOMMODATIONS

What accommodations have you had in the past?

List any past academic accommodations and support services you have received, including any augmentative or assistive devices used, ACT/SAT accommodations from a previous college, IEP accommodations, and 504 plan accommodations.

What accommodations are you requesting?

Accommodation Information

Accommodation Type

Explanation of Accommodation:

Please give details of your request as needed. If you selected "Other," specify the accommodation you are requesting.

Semester

Disability Services Application

CEDARVILLE UNIVERSITY DISABILITY SERVICES

Section I: STUDENT PROFILE

Section II: ACCESSIBILITY ACCOMMODATIONS

Accommodation Information

Document Information