DEADLINES: Students admitted for August—form is ... - Champlain College

Accommodation Request Form

Please return the completed form by the appropriate due date to: Office of Accessibility, Champlain College, P.O. Box 670, Burlington, VT 05402. Forms may also be sent via email to accessibility@champlain.edu.

DEADLINES: Students admitted for August--form is due June 01. / Students admitted for January--form is due December 15.

Champlain College is aware that many individuals have physical, medical, psychiatric or learning disabilities, and is committed to ensuring that all students have equal access to its programs. If you would like to request accommodations, please complete this form and attach documentation from your treatment provider. Once your documentation has been received and is reviewed, Champlain's Office of Accessibility will contact you to schedule a meeting prior to the start of the semester.

Residential

Commuter

Online Check one First-Year

Sophomore

Junior

Senior

Transfer

Grad

Date of Birth Last Name Preferred Name Street Address City, State, Zip Code Email Address Alternative Phone Number

Major First Name

Student ID Number

Cell Phone Number

Middle Initial

Primary Condition: Secondary Condition: Please describe how your condition(s) impacts your daily life and education:

18-SS-3100_5/1

Continued >

What accommodations are you requesting?

Have you received accommodations in the past? Yes

No

If yes, what accommodations have you used?

Are you interested in Champlain College's Counseling Services? Yes

No

Are you interested in Champlain College's Academic Coaching? Yes

No

Additional Comments:

For housing accommodations, please submit the Housing Accommodations Request Form.

Student Signature

Date

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