Disability Accommodation Request Form A student who requests reasonable accommodations related to a disability must provide information and recent documentation to the Coordinator of Student Disability Services concerning the specific disability or condition, and the desired accommodations as specified by a physician or an appropriate professional. Grace College and Seminary desires to assist students with disabilities and help them realize their personal educational goals by working for reasonable accommodations in the academic environment. Please help us serve you by providing the information requested below. Name:*Cell Phone Number:I give my approval to share my information with:*Academic AdvisorFacultyWellness & Health Center/ Counseling OfficeHousingStudent AffairsFood Service Academic InformationI am a /an ___________ student:*Undergraduate: Winona LakeUndergraduate: AkronGOAL: OnlineGOAL: Winona LakeGraduate/Seminary: OnlineGraduate/Seminary: Winona LakeMy classes start in the:*FallSpringSummerYear* Nature of DisabilityPlease provide a brief description of the nature of your disability. Indicate accommodations generally required to assist you in your educational/campus life experience. Physical Impairment:Accommodations Requested: Sensory Impairment:Accommodations Requested: Specific Learning Disability:Accommodations Requested: Other:Accommodations Requested: Please upload official documentation describing your disability.Official Documentation Form Review* This information is correct to the best of my knowledge. Name* First Last Date* Questions? Email The Learning Center or call 574-372-5100 ext. 6423.