Office of Accessibility Registration Form

Academic Accommodations Registration

Morrow Academic Center / Office of Accessibility
Student Information
Full Name*

First Name Middle Name Last Name
Preferred Name
Date of Birth*

MonthDay Year
Date
Preferred Pronoun
Student ID*
Semester of Enrollment*
Student Classification*
Adviser*

First Name Last Name
Contact Information
Email*
firstname.lastname@lyon.edu
Local Address*

Street Address

Street Address Line 2

City State

Zip Code
Home Address*

Street Address

Street Address Line 2

City State

Zip Code
Phone Number*
Is the provided phone number above a mobile phone that is text-enabled?*

YesNo
If a text-enabled number, do you give permission for occasional texts from the Director of Academic Support to deliver reminders to you of meetings or important emails to read?*

YesNo
Emergency Contact Information
Name*

First Name Last Name
Relationship to Student*
Specialist/Physician Contact Information
Name*

First Name Last Name
Specialist/Physician Facility*
Address*

Street Address

Street Address Line 2

City State

Zip Code
Phone Number*
Please enter a valid phone number.
Condition Information
Select all that apply.*

DeafHard of HearingBlindLow VisionLearning DisabilityPsychiatric/EmotionalSpeech ImpairementMobility ImpairementSubstance AbuseChronic IllnessTemporary ConditionOther
Condition resulted from:*
Has this condition affected you since birth?*

YesNo
If no, when were you diagnosed with this condition?
Identify specific condition and describe how you were diagnosed. Then, describe your symptoms and the ways in which they affect your daily life and education. *
Reasonable Accommodations

Select the services that may apply. Requested accommodations must be reasonable and directly relate to the barriers that arise as a result of your condition.
General Services

Assistive Devices/Equipment LoanBooks in Alternate FormatCourse SubstitutionDisability ParkingInterpreterRegistration AssistanceSelf-Advocacy SkillsTutoring/SI/Writing Center/Peer Academic CoachingOther
If you selected "Other," please explain.
Testing Services

Extended TimeInterpreterLarge-PrintLow-Distraction RoomReaderScribeUse of ComputerOther
If you selected "Other," please explain.
Classroom Services

Lab AssistanceClassroom SetupClosed CaptioningInterpreterLarge-PrintLecture Notes/SlidesAudio Recorded LecturesOther
If you selected "Other," please explain.
Emergency Procedures
Can you walk without assistance?*

YesNo
If you cannot walk without assistance, can you walk if assistance is provided?*

YesNo
Can you hear a fire alarm?*

YesNo
Can you maneuver stairs without assistance?*

YesNo
If you cannot maneuver stairs without assistance, can you maneuver stairs if assistance is provided?*

YesNo
Do you need to be carried?*

YesNo
Do you need assistance exiting a building?*

YesNo
Do you have seizures?*

YesNo
If you selected "Yes," what kind of seizures do you experience?
If requesting seizure first-aid, provide specific instructions.
Do you have a health condition that requires Lyon College personnel to have special instructions or prior knowledge of condition?*

YesNo
If you selected "Yes," provide specific instructions for any assistance requests and any other information personnel may find useful.
Required Documentation

In order to ensure accommodations can be provided, you must provide documentation that verifies evaluation from a licensed medical or ADA disability services professional. You must provide some or all of the following documents by mailing or delivering them to the Office of Accessibility. Mailed documents should be sent to: Office of Accessibility / Morrow Academic Center / Lyon College / 2300 Highland Rd. / Batesville, AR 72501. The office of disability services may request additional information.
Documentation Provided*

Medical Documentation (physician's letter, medical records, etc.)Educational Information (504, IEP, etc.)Other
Upload your disability documentation here:

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Intake Appointment

Once intake forms are received, the student must attend an intake meeting with the Office of Accessibility.
Please identify a potential intake meeting date and time. The Office of Accessibility will contact you with confirmation of the appointment. Appointments are not confirmed without written notification from the Office of Accessibility. *
Grievance Policy
Any student who believes he/she/they has been subjected to discrimination on the basis of disability may file a grievance under this procedure. It is against the law for Lyon College to retaliate against anyone who files a grievance or cooperates in the investigation of a grievance.
1. Grievances must be submitted to the Director of Academic Support in the Office of Accessibility within 14 days of the date the person filing the grievance becomes aware of the alleged discriminatory action.
2. A complaint must be in writing and contain the name, address, and other applicable contact information of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.
3. The Director of Academic Support shall investigate the complaint. This investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Director of Academic Support will maintain the files and records of Lyon College relating to such grievances.
4. The Director of Academic Support will issue a written decision on the grievance no later than 30 days after its filing.
5. The person filing the grievance may appeal the decision of the Director of Academic Support by writing to the Provost within 14 days of receiving the decision of the Director of Academic Support. The Provost shall issue a written decision in response to the appeal no later than 30 days after its filing.
6. The availability and use of the grievance procedure do not prevent a person from filing a complaint of discrimination on the basis of disability with the US Department of Health and Human Services, Office for Civil Rights.
To avoid conflict of interest, grievances filed against the Lyon College Office of Accessibility and/or its representatives should be submitted to the Provost within 14 days of the date the person filing the grievance becomes aware of the alleged discriminatory action. The Provost shall issue a written decision in response to the grievance no later than 30 days after its filing.

Lyon College will make appropriate arrangements to ensure persons with disabilities are provided other accommodations, if needed, to participate in the grievance process. Such arrangements may include but are not limited to providing interpreters for the deaf, providing audio of material for the blind, or assuring a barrier-free location for the proceedings. The Director of Academic Support will be responsible for such arrangements.
Attestation, Permissions, and Releases

By signing below, you attest that all information in this intake form is accurate to the best of your knowledge. You attest further that you have read and understand Lyon College's Office of Academic Support and Accessibility Grievance Policy.
Student Signature *

Clear
Permission

By signing below, I give the Office of Academic Support and Accessibility permission to contact the professors in courses in which I am registered in the selected semester regarding my requested academic accommodations.
Signature

Clear
Attestation and Permission

By signing below, I
- attest that all information in this registration form is accurate to the best of my knowledge;
- attest that I have read and understand Lyon College's Office of Academic Support and Accessibility Grievance Policy;
- give permission to the Office of Academic Support and Accessibility to contact and discuss my condition and needs with appropriate college personnel including advisor(s), professors, Student Life Office personnel, Academic Services personnel, Athletic Department personnel, College counsel, and other parties deemed necessary by the Office of Academic Support and Accessibility to have a justified interest in providing me reasonable academic accommodations and modifications at Lyon College.
If you want to exclude certain courses from consideration for academic accommodations or modifications in the semester you are registering for accommodations, please list those courses below. Type 'Not Applicable' if you do not want to exclude any courses.*
Signature for attestation and permission

Clear
Should be Empty:

Academic Accommodations Registration

Student Information

Contact Information

Emergency Contact Information

Specialist/Physician Contact Information

Condition Information

Reasonable Accommodations

Emergency Procedures

Required Documentation

Intake Appointment

Grievance Policy

Attestation, Permissions, and Releases

Permission