Student Accommodation Request

Student Information

Welcome to the Office of Student Accommodations, if you have any questions please contact us at 804-523-5628, 804-523-5290 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

Pronouns

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:

Please specify if other

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

I also give consent for Reynolds Community College to release information to any of the below per my request:

Please check all the apply

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.

Signature

Date

Commonwealth of Virginia Voter Registration Agency Certification

Documentation

To be eligible for services and accommodations through the OSA, students must 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.

Upload documentation

Student Accommodation Request

Student Information

Disability Information

Documentation

Document Information