Disability Disclosure and Accommodation Request Form

This form documents your self-disclosure of your disability and your request for accommodations. Information received in the Office of Accessibility Services is kept confidential at the highest level possible. If you need assistance in completing this form, please contact the Office of Accessibility Services at (419) 824-3523 or oas@lourdes.edu.

First and Last Name:*
Email:*
Phone:*
Are you a current Lourdes University student?*
Please disclose your disability*
How long have you had this diagnosis/disability?*
Did you receive academic accommodations in the past? If so, please list your previous accommodations.*
By including my typed name as my electronic signature below and submitting the above information, I certify that all of the information within this form is accurate. I also understand that further identification and/or information may be requested in order to process my request.
Signature*
Date*
MM slash DD slash YYYY
By pressing the submit button, your information will be sent directly to the Office of Accessibility Services. Please allow one to two business days for a response to your request. Thank You!