724c Southwestern University: Academics

Southwestern

Engaging Minds, Transforming Lives

Advanced Entry 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 qualified 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:

  • Complete this electronic form (or return the PDF version of the Disability Disclosure Form to the Center for Academic Success, Attn: Kimele Carter). 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.
  • All students requesting accommodations must provide current (within 3 years) and age-appropriate documentation from a qualified professional. Information on appropriate documentation can be obtained by contacting the Assistant Director for Academic and Access Resources and are also available here.
  • To ensure adequate time to process and discuss potential accommodations, contact Kimele Carter by June 10, 2011 (or when submitting your AES enrollment form, whichever comes first). Contact information for Kimele is: 512-863-1536 (phone) or via email at carterk@southwestern.edu.
  • Accommodations are class specific and it is the student’s responsibility to request accommodations. Within the first two weeks of class, schedule an individual meeting with the Assistant Director for Advising and Access Resources to solidify final arrangements for accommodations.
  • Required fields are designated with an asterisk.

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 Used prior to college 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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