478b Southwestern University: Academics: Faculty Notables

Southwestern

Engaging Minds, Transforming Lives

First-Year Seminar

Disability Disclosure Form

Southwestern University, in compliance with Section 504 of the Rehabilitation Act of 1973 and The Americans with Disabilities Act of 1990, recognizes that students who have diagnosed disabilities including specific learning, physical, or psychological disabilities, are entitled to an equal opportunity to benefit from the educational programs of the University and that reasonable accommodations may be necessary to provide that opportunity to students with disabilities.

The Center for Academic Success coordinates services for students with disabilities. Students wishing to request accommodations from Southwestern University should follow the steps below. All information about a student’s disability is considered to be confidential and will remain within the office of the Assistant Director for Advising and Access Resources (Maria Peña).  Please see the Disability Resources page for information about Confidentiality Practices.

Complete this form (the Disability Disclosure form) or return a hard-copy to the Center for Academic Success, Attn:  Maria Peña.

Provide documentation by July 22, 2013 from a qualified professional that describes the functional impact/limitations that result from the disability.  Information on acceptable documentation is available on the Disability Resources page or by contacting Maria Peña by e-mail penam@southwestern.edu or phone 512.863.1536.

Contact Maria Peña to set up a meeting to discuss potential accommodations within the first two weeks of class.

1. YOUR INFORMATION

Name* (first/middle/last):
Preferred name*
Mailing Address*
Mailing Address 2
City*  State*:
Zip Code*
Email*
Nature of Disability

2. SERVICES

Please indicate below which services you anticipate using. The Assistant Director for Advising and Access Resources will use these responses as a means for determining what is reasonable and appropriate for you. Actual accommodations depend upon the Assistant Director's review of appropriate documentation.

Service Anticipate using at Southwestern
Audio Texts
Extended time testing
Reduced Distraction Testing
Note Takers
Readers
Scribes
Physical Modifications (explain below)
Reduced Course Load
Interpreter or Captioning

3. OTHER

Please use this field to give us more information on physical modifications you anticipate using at Southwestern or any other service not listed above.

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