EmailMeForm
Request for Disability Accommodation
This form is intended for Wartburg students who want to self-disclose their status as a person in the protected class of disability, as well as to request review of information to access accommodations and services, if needed.
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First Name
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Middle Name
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Last Name
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Preferred Name
Cell Phone
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Home Phone
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Email
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Student ID Number
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Emergency Contact
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Emergency Contact Relationship
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Emergency Contact Phone
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What is your current status?
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Incoming First Year
Incoming Transfer
Current Student
Other
Major(s)/Minor(s)
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Which of the following best identifies your disability or disabilities? You may select more than one answer.
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ADHD
Autism Spectrum
Chronic Medical
Hearing
Learning
Mental Health
Mobility
Orthopedic
Visual
Traumatic Brain Injury
Unknown/Unsure: I am submitting this form to explore whether I qualify for disability services
Other
Are you requesting disability services at this time?
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No - I am not requesting disability services or accommodations at this time. (You may skip the non-required questions on the next page.)
Yes - I am requesting disability services at this time. (Please respond to all remaining questions and submit disability documentation)
Maybe - I am submitting the form to explore whether or not I may qualify for disability services.
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