Student Accommodation Request

Student Information

Welcome to the Office of Student Accommodations, if you have any questions please contact us at 804-523-5290 (PRC), 804-523-5628 (DTC) or email osa@reynolds.edu. Please note applications must be completed in one setting can not be saved for later.

First Name

Last Name

Middle Name

Preferred Name

Student ID

Enter 7 0s if no ID is assigned yet

Email

Primary Phone Number

Secondary Phone Number

Disability Information

Disability/diagnosis

Select all that apply

If other, please specify

Affiliation(s)

Have you received prior accommodation(s)?

Requested accommodations at Reynolds:

How do you see these accommodations relating to your disability? How will they support you? Please describe:

Have you used any accessible/assistive technology before, including reading or writing software?

Is there any other information you would like to share relating to your disability? Please describe:

Emergency Contact Information: Provide the following information in the box below, name, relationship, and phone number.

Office of Student Accommodations Release of Information and Procedures for Emergency Medical Occurrence:

If your disability could possibly create a situation where you would need emergency assistance please answer yes or no

Educational Need to Know

I give permission for Office of Student Accommodations (OSA) to discuss my educational situation with other professionals who have a legitimate educational need to know. This authorization shall remain in effect until revoked in writing by the student.

Student Responsibilities Agreement

The Student Responsibilities Agreement addresses the responsibilities of the student associated with accommodations, and the statement is as follows: I understand that I must request accommodations at the beginning of each semester and any time there is a class added to my schedule. I understand that I am responsible for communicating with my instructors about my accommodations should I choose to implement them. I understand that I am responsible for communicating with my instructors should I intend to use my testing accommodations at least 48 hours prior to the exam(s). I understand that I am responsible for coordinating testing with my instructor and the Office of Student Accessibility when using approved testing accommodations, which should be done at least 3 business days in advance. I understand that I will be responsible for contacting the instructor and/or the Office of Accessibility to inform them of any necessary schedule changes. I will be on time to all classes and tutoring sessions. I will notify the Office of Student Accessibility if I need books in an alternate format at least 2 weeks prior to the start of the semester, and I will follow appropriate procedures for requesting books. I will notify the Office of Student Accessibility if I need notes transcribed, enlarged, or other specialized services at least 2 weeks prior to the start of the class. I understand that it can take up to 30 days after submitting an application to have accommodations in place for class, which may be impacted by certain requests such adaptive or alternative equipment, books, assistive technology, and other services. I understand that all information concerning my disability is confidential, and so I am responsible for notifying the Office of Student Accessibility of any problems or difficulties with my accommodations. Signing below with your full name indicates that I agree with this statement.

Signature

Date

Commonwealth of Virginia Voter Registration Agency Certification

Documentation

To be eligible for services and accommodations through the OSA, students may be required to submit documentation that verifies their disability and, therefore, their eligibility under Section 504 of the Rehabilitation Act, the Americans with Disabilities Act (ADA) and the ADA Amendments Act. Click here to read our Documentation Guidelines. If you have any questions regarding documentation, please email us and we would be happy to speak with you and answer any questions you may have.

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