Request for Disabilities

Name

First Name Last Name

Park ID#:

Date of request:

Month Day Year

Are you currently attending classes at Park University?

Yes No

If no, what term/semester will you be attending?

I plan to take classes at (check all that apply):

Parkville Gilbert Online Campus Center

Please Specify Campus Center *

Type of disability:

Physical Learning other

Specify the type of disability:

Do you have documentation from a medical professional qualified to diagnose this disability?

Yes No

If you do not have the documentation, please visit our website for more information on the documents needed:

www.park.edu/disability

If yes, describe the documentation type and date. You may submit your documentation via email to: disabilityservices@park.edu | Fax it to: 816-505-5445 | Mail or drop off to our office ASC Park University 8700 NW River Park Drive CMB 46, Parkville, MO 64152

Accommodation requested: *

Are you currently served by Voc. Rehab?

Yes No

If yes, please indicate state

NOTE: Accommodations are approved based upon the documentation we receive. We must also consider requirements of academic departments as we determine reasonable accommodations. Accommodations approved for a student may or may not include all accommodations requested. Please refer to the Handbook for Students with Disabilities for more information about the review process and grievance procedures.

You can also download this form and submit it via mail, fax, or email to: Florenda Jarrard Assistant Director of Academic Success Park University 8700 NW River Park Drive CMB 46 Parkville, MO 64152 Fax: 816-505-5445

Email: disabilityservices@park.edu

Phone: 816-584-6313

If you prefer to download a paper application click here

Student Request for Disability Services