OFFICE OF STUDENT ACCESSIBILITY & ACCOMMODATION



STUDENT REQUEST FOR ACCOMMODATION FOR REASON OF DISABILITY

ACADEMIC TERM/YEAR: _______________________________________

PROGRAM/COURSE OF STUDY: ___________________________________

We define a disability as a functional limitation caused by a long term or recurring physical, sensory, mental, psychiatric or learning impairment that restricts the ability of a person to perform the activities necessary to participate in learning or daily living at Dalhousie University.

NAME: _________________________________________STUDENT #: B00_____________________________

Email: ___________________________Phone (h): ______________________(c): __________________

Permanent Mailing Address: __________________________________________________________________

Province: ____________________________________ Postal Code: __________________________________

STATUS: (Nova Scotia Student, Out of Province Student, International Student): ______________________________

Reason for Request (check one or more, if applicable)

_____ Learning disability _____ ADHD/ADD

_____ Mental health disability _____ Physical disability

_____ Other disability. Please specify: __________________________________________________________

Please complete this Form for processing BEFORE the academic term begins. This will enable appropriate accommodations to be put in place as early as possible.

Complete the form in its entirety.

Advising may also be necessary for students as part of the decision process for your request. Appointments can occur by telephone or in person. You will be contacted by email or telephone if an appointment with the Program Director is required.

SECTION A:

Please explain how your disability has an impact on your learning or your daily living at the College of Continuing Education and/or University.

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Please describe the accommodations you are requesting to minimize the barriers created by your disability. Please be as specific as possible. Attach additional pages if necessary. This request can be discussed in full with the Program Director/Advisor and can be revised, if appropriate.

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Signature: ________________________________ Date: __________________________________

SECTION B:

If you are seeking a change in your accommodations, please specify the change you are requesting and why. (You may be contacted to arrange an appointment.) __________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Signature: ________________________________ Date: _________________________________

SECTION C: All students must complete this section.

Please list the Course Title & Instructor (if known) for which you are requesting accommodations.

Course: ____________________________ Instructor: _______________________________

Course: ____________________________ Instructor: _______________________________

Course: ____________________________ Instructor: _______________________________

Signature: Date: ___________________________________

IMPORTANT INFORMATION FOR ALL STUDENTS

Requests for accommodation cannot be assessed until all supporting documents and information are received by the College, and you attend appointments as required. You may be asked to obtain additional medical or other reports to meet documentation criteria.

If your request relates to a learning disability, you must provide a current psycho-educational report describing the nature of the learning disability, assessment and descriptions of functional limitations, and recommendations for accommodations.

If your request relates to any other disability, you must provide a current medical report containing a diagnosis of the disability, description of functional limitations, and recommendations for accommodations.

If you have previously submitted medical documents to the Advising & Access Services Centre at Dalhousie University, we ask that you request that a copy be shared with the College (and no further documents are required).

Signature: ____________________________________________ Date: _______________________________

Please return to:

Dalhousie University College of Continuing Education

Suite 2201 – 1459 LeMarchant Street

PO Box 15000

6227 University Avenue

Halifax, Nova Scotia B3H 4R2

Ph: 902-494-1468 Fax: 902-494-3662

For office use only:

Date request was received: _________________________

Date of Appointment with Advisor (if required: _____________________

Name of Advisor: ________________________

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