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 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 of Academic Success (Maria Peña).

  1. Complete this electronic form (or return the PDF version of the Disability Disclosure Form to the Center for Academic Success, Attn: Maria Peña.
  2. Provide documentation from a qualified professional that describes the functional impact/limitations that result from the disability. Information on acceptable documentation is available here or by contacting Maria Peña (penam@southwestern.edu).
  3. Set up a meeting to discuss potential accommodations within the first two weeks of class by contacting Maria Peña. Contact information for Maria is at the bottom of this form.
  4. If it is your first visit, complete the intake form and mail it in or bring it with you to your first appointment.
  5. 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 check which services you have used in the past and which you hope to use at Southwestern. The Assistant Director will use these responses, a thorough review of documentation and interview and intake information as a means for determining what is reasonable and appropriate to include in your accommodation package.

Service Used in the past Hope to use 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.