Disability Eligibility Determination and Accommodation Request Form

* indicates a required field

Student Information

The purpose of this form is to assist the University in determining whether, or to what extent a reasonable disability accommodation is required. Questions related to the completion of this form or requests for assistance should be addressed to Ravan Anderson in the Student Affairs Office located in the East building, Suite E200, (972) 438-9632 ext.7153. To insure timely and effective provision of services, accommodations should be requested at least one month in advance. However, requests may be made at any time, and efforts will be made to accommodate eligible requests as soon as possible. This form is for the voluntary disclosure of a disability only. You are not required to complete it unless you are requesting accommodations for a disability.

For more information about Eligibility Guidelines, please see https://my.parker.edu/ICS/Campus_Life/Student_Affairs/Disability_Services/

Eligibility for support services for students with disabilities depends upon evaluation of the following requirements by the Office of Student Affairs:

· Student has been recently assessed (preferably within five years of the term for which the student requests accommodations) comprehensively and is determined to have a specific and significant functional impairment in the educational setting;

· Student provides verification of diagnosis, longevity, and severity of disability by a licensed psychologist, physician, and/or other relevant, competent professional; and

· Diagnosing professional provides specific recommendations for accommodations to aid student in the educational process by reducing the effects of the impairments caused by the disability.

First Name

Last Name

Middle Name

Student ID

Please use your university issued email address

Phone Number

Specific Accommodation Information

Briefly identify and describe the nature of your disability

My diagnosed disability falls into the following category

Did you previously have academic accommodations in school?

If yes, please explain.

Date of your most recent psychoeducational or medical evaluation

Note: This application cannot be processed until pertinent documentation of a disability has been provided. To ensure the provision of reasonable and appropriate accommodations, students requesting these services must provide comprehensive documentation of their disability to satisfy the eligibility requirements listed above. Appropriate services will be determined from the specific information provided. The University may arrange for an additional independent evaluation as it may deem necessary.

What accommodations do you feel that you need in order to pursue your education at Parker University?

Specific Accommodations

Has a physician, vocational rehabilitation specialist or other qualified health professional recommended a specific accommodation?

Is so, please describe the service recommended/received, the name of your health provider, and his/her phone number.

Authorization

By checking this box, I authorize the release of all relevant information, records and documentation to professors and other relevant parties of the Parker University for the purpose of determining my eligibility for disability accommodations related to my enrollment or participation in courses, programs, or activities offered by the University. I understand that select administrators and faculty with a need to know, as determined by the University will review copies of all documentation provided.

Upload supporting document(s)

Disability Eligibility Determination and Accommodation Request Form

Student Information

Specific Accommodation Information

Document Information