Request for Accommodations Form

Xavier College Preparatory High School

Request for Accommodations
A. Student Information / Name*

First NameMiddle NameLast Name
Gender*
Birth Date*

MonthDayYear
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
School Presently Attending*
Current Grade Level*
Parent/Guardian 1 / Name*

First NameMiddle NameLast Name
Parent/Guardian 1 / Mobile Number*

Area CodePhone Number
Parent/Guardian 1 / E-mail*
Parent/Guardian 2 / Name

First NameMiddle NameLast Name
Parent/Guardian 2 / Mobile Number

Area CodePhone Number
Parent/Guardian 2 / E-mail

Area CodePhone Number
B. Accommodation(s) Currently Receiving (Check all that apply)*

Extended Time (50%)Mark answers in test book (not on scantron answer document)Preferential seatingOther
C. Diagnosed Disorder/Disability (Check all that apply)*

Reading Disorder (including Dyslexia)Mathematics DisorderWriting Disorder/Written ExpressionSpeech/Language or Communication DisorderADD/ADHDMood or Anxiety DisorderHearing ImpairmentVisual ImpairmentPhysical ImpairmentOther
D. Current IEP, 504, or Official Accommodations Plan (Check the box to indicate which type of plan you are submitting)*

IEP504 PlanOfficial Accommodation PlanMedical Verification Form
Check ALL school years in which the student has officially been permitted by school to access the above requested accommodations.*

Grade 8Grade 7Grade 6Grade 5Grade 4Grade 3Before Grade 3
E. Documentation Upload

Please include your child's most recent documentation. Documentation includes any of the following:
- Psychoeducational / Neuropsychological Evaluation (completed by a licensed practitioner)
- IEP
- 504 Plan
- Official Accommodation Plan
- Medical Documentation
Documentation Upload*

Browse Files
Documentation Upload Cancelof
F. Parent/Guardian Signature
Terms and Conditions
By clicking above on Terms and Conditions, I certify that I am the person whose information is submitted on this request form and that the information provided is accurate to the best of my knowledge. By signing below, I understand that the information submitted my be kept by Xavier College Preparatory High School with other self-identifying information for the duration of my tenure as a student at Xavie College Preparatory High School.

I authorize release to Xavier College Preparatory High School diagnostic and educational information by school officials, physicians, educational evaluators, or others having such information as related to my request for accommodations on the HSPT. All information will be handled confidentially, and will not be released to parties outside of Xavier College Preparatory High School without prior written consent.
G. Submission of Request for Accommodations on Xavier's HSPT (High School Placement Test)

Click on Submit Application below to complete your request for accommodations.

Any questions, please contact Andrea St. Onge, Xavier's Learning Specialist, at astonge@xavierprep.org or (760) 601-3900 ext 6245

Thank you for your interest in Xavier College Preparatory High School. You will receive e-mail notification of our receipt of your application to request accommodations.
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Xavier College Preparatory High School