Bellarmine Accommodation Request

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Student Information

Welcome to Bellarmine University Disability Services.  In order to receive accommodations, students must complete the following form and attach documentation of disability. If you have questions about what type of documentation to include, please review the University's documentation guidelines at http://www.bellarmine.edu/studentaffairs/disabilityservices/

To receive prompt accommodations and services, students are advised to submit a request with documentation at least two weeks in advance of when they would like accommodations to be implemented. Please note that some accommodations may take longer to implement than others. If problems or questions arise, please contact us at rpurdy@bellarmine.edu.

Please read all instructions carefully when completing this form. You MUST COMPLETE ALL FIELDS before submitting this form.

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Please use your university issued email address
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Are you requesting academic accommodations?
Are you requesting housing accommodations?

Specific Accommodation Information

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Have you used accommodations in a previous setting?(Required) *
Confidentiality Agreement(Required) *

Information provided to Disability Services is protected by FERPA and granted the same level of confidentiality as other student records, which may only be shared with other institutional employees/departments on a “need to know” basis or with your written permission.  Disability Services records/information are not covered by state laws that govern mental health records.  As such, the Director of Disability Services may be obligated to report information such as sexual assaults, criminal/judicial misconduct or academic dishonesty.

In order to determine reasonable accommodations and to coordinate your academic adjustments/accommodations, Disability Services will need to communicate with university’s administration, faculty and/or staff.  Information that is shared will be limited to only essential information (i.e. that you have a documented disability and what accommodations you are eligible to receive).

I give permission for staff of Disability Services to share information about my disability-related needs on a need-to-know basis.  I understand that this authorization may be withdrawn at any time by submitting a written, signed, and dated request to the Director of Disability services.