Disability Self-Disclosure Form

Disability Self-Disclosure Form
Required of students requesting academic accommodations.
If you are a student with a disability and wish to request accommodations, please complete this form. You also must provide documentation of your disability as detailed on the College website. All documentation will be kept confidential and maintained separately from your student academic record.
Name *

First Name Middle Initial Last Name
Email *
example@example.com
Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number

Area Code Phone Number
Cell Phone Number *

Area Code Phone Number
Describe your disability(ies): *
Describe how your disability(ies) affects your learning & participation in an academic environment and/or a residential environment: *
What support services or accommodations did you receive in high school? *
What support services or accommodations do you plan to ask for at Hiram College? *
Students must complete this form and provide current, detailed documentation before accommodations can be provided. I hereby authorize the Director of Counseling, Health and Disability Services to disclose information about my accommodation needs to my faculty and personnel directly involved in providing academic, residential or support services. I understand that Hiram College reserves the right to request additional or more current documentation in order to identify a disability and/or appropriate accommodations.
Signature *
Date *

Month Day Year
Date
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Questions: 330-569-5418 (office), 330-569-5398 (fax), feisthamelkp@hiram.edu (email)
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