Disability Accommodation Request Form

In order to evaluate how Providence College can best meet your needs, we need specific information from both you and your health care provider. Please complete the form below and submit. In addition, the Medical Documentation Form must be completed by your health care provider. That form can be found by clicking on Medical Documentation Form and printing the form to submit to your health care provider.

First Name:

Middle Name:

Last Name:

Banner ID:

If you are a new student and have not received your Banner ID yet, please enter “000000000”

Birth Date:

Gender:

Email Address:

Current Class Year

Home Street Address:

Home City:

Home State:

Home Zip Code:

Home Telephone:

Cell Phone:

On-Campus Residence Hall:

Is this a new accommodation request?

YesNo

Is this a renewal for previously approved accommodations?

YesNo

If a renewal, are there any changes requested? (any changes would require that new medical documentation be submitted)

YesNo

PLEASE NOTE: Accommodations, if granted, are for you alone and do not apply to roommates or housing groups.

1. Please Describe the nature and extent of your disability (for example, hearing loss 80% or asthma, chronic).

2. Approximate date you were first diagnosed by medical provider?

3. What accommodation are you seeking at this time to mitigate the effects of your disability?

4. What accommodations have you previously received at Providence College?

5. What accommodations have you previously received in high school or other institution?

Deadlines for submission of request forms:

Semester	Submit by
Fall	March 1 (July 1 for new students)
Spring	November 1
Summer	May 1

6. If application is being submitted after deadline, please explain reason for delay in submission (must be completed if past deadline):

Contact Information