Accommodation Request Form

Student Information

Please enter your information

First Name

Last Name

Middle Name

Preferred Pronoun

Preferred Nickname

Student ID

Email

Please use your university issued email address

Alternate Email Address

Cell Phone Number

Alternate Phone Number

Date of Birth

Enrollment Status

Please list the name(s) of your high school(s):

Please list any other college or universities you may have attended (if applicable):

Have you declared a major?

Do you plan to, or are you currently living on campus?

DISABILITY AND ACCOMMODATION INFORMATION

What is the disability or chronic illness you are requesting accommodations for?

Please provide a brief description of your disability or chronic illness:

When was your disability or chronic illness first diagnosed (approximately)?

Have you ever received reasonable accommodations based on disability or chronic illness in the past?

If so, what accommodations have you received in the past?

How does your disability/illness affect you academically?

How does your disability/illness affect outside the classroom?

EXTRACURRICULAR/CO-CURRICULAR ACTIVITIES

Are you a Molloy University Student Athlete?

Do you have a job outside school?

Are you involved in any Molloy College clubs?

Would you be interested in participating in discussion groups?

Our office holds Discussion Groups that are a place for students to bring lunch and chat. Dessert is provided. Are you interested?

Would you like to be added to the L.E.A.D. Club mailing list? (Leadership, Education, and Awareness of Disabilities)

L.E.A.D. is a Molloy College club (Leadership, Education, and Awareness of Disabilities). It is open to all Molloy students who have an interest in spreading awareness.

Please feel free to tell us something about yourself that you would like for us to know.

SUPPORTING DOCUMENTATION

PLEASE UPLOAD YOUR SUPPORTING DOCUMENTATION:

DOCUMENTATION GUIDELINES

Acceptable Documentation :

Examples are IEP or 504 Plan or a letter from your healthcare provider that:

- States a specific diagnosis

- Describes the current functional impact

- Is recent (within the last 3 years)

- Is comprehensive

- Includes recommendation for accommodations

- Evaluation must be completed by a properly credentialed professional who has no personal relationship with the individual being evaluated

Keep in Mind

- All documentation will be reviewed with the Access Directors on an individual case-by-case basis

- Determination of accommodations is an ongoing and interactive process

- Documentation of a specific disability does not guarantee specific accommodations