Student Accommodation Application

Student Accommodation Application
If you would like to receive accommodations at Richmont Graduate University, please complete the below Student Accommodation Application, and send it, along with your documentation from a licensed provider, to the Office of Student Affairs.

At the end of the application, please upload your supporting documentation from a licensed professional who has relevant training and experience diagnosing the reported condition.

Student Accommodations will be processed within 2-3 business days after completion of the application and submission of all necessary documentation from a licensed provider.
Name*

First NameLast Name
Type your Richmont email address: (example: first.lastname@richmont.edu)*
Select your home/primary campus:*

AtlantaChattanoogaOnline
Type your street/mailing address*

Street Address

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CityState / Province

Postal / Zip Code
Type your phone number:*
Please enter a valid phone number.
Type your date of birth:*

MonthDayYear
Date
Gender

FemaleMaleNon-binary
Select your Richmont affiliation + degree program:*

School of Counseling – MA Clinical Mental Health CounselingSchool of Counseling—MA Pastoral Care & IntegrationSchool of Ministry—MA in MinistrySchool of Ministry – MA in Spiritual Formation & DirectionOther
What relevant (I.e., relevant to your requested accommodations) diagnoses have you been given, and by whom (licensed provider)? *
Please describe your disabilities and/or functional limitations:
What accommodations has your provider recommended that you request as a student at Richmont?*

Additional Time on Exams/Quizzes (x2)Quiet, Separate Space for In-Person Exams/QuizzesAttendance Requirement ModificationDeadline ModificationOther
What other accommodations has your provider recommended you have in a school setting? Please list them as they are described in your provider's documentation.
Have you received services for your disability in previous educational settings?*

YesNo
Please select all applicable educational settings:

UndergraduateGraduate
Please list the specific accommodation(s) you received in an undergraduate school setting:
Please list the specific accommodation(s) you received in another graduate school setting:
Please type the name(s) of the licensed providers who you have (or are) working with you regarding your functional limitations and the dates you received these services: *
Supporting Documentation:

Documentation should be current, preferably within the last 3 years. (The age of acceptable documentation is dependent on the disabling condition. For example, older documentation may be accepted for conditions that are permanent.)

Documentation is required to be on professional letterhead with the name, title, address, and phone number of the professional.

Please provide documentation from a licensed professional who has relevant training and experience diagnosing the reported condition.

Documentation needs to be typed, dated, signed, and should include the following information:
- Credentials of the evaluator
- Clear diagnostic statement with specific diagnostic code
- Description of the methodology used and test scores that support the diagnosis
- Description of current functional limitations that may affect academic performance
- Rating of severity & prognosis of the condition
- Any medications that are currently used
- Recommended accommodations that are related to functional limitations
SUPPORTING DOCUMENTATION *

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Upload PDF Attachment Options (6 total possible uploads – PDF Only allowed)
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I understand that Richmont Graduate University provides reasonable accommodations to students in compliance with the Americans with Disabilities Act of 1990.
I understand that "reasonable accommodations" cannot result in substantial changes to the essential elements of the university curriculum, substantial alternations in the manner in which courses (or course assignments) are provided, or anything that substantially alters the class learning experience and learning outcomes.

Completion of this application does not ensure my requested accommodations. All accommodations need to be approved by the Office of Student Affairs.

Approved accommodations are based on review of documentation specific for each disability and its impact and a student's functional limitations.

I understand that my provider needs to request the specific (specific time amount, specific deadline alternations, etc.) accommodations in order to provide the university clarity on how to best assist the student.
Once approved, I understand that I will need to tell the Office of Student Affairs my schedule (course name, section number, and professor name) each semester so they can communicate with my professors on my behalf.
I understand that by signing this form, I authorize the Office of Student Affairs (ADA Coordinator) to provide information for accommodations to my professors and to my advisor so that reasonable accommodations can be implemented and to enhance my educational planning.
I understand this authorization is voluntary and I may revoke this consent at any time through a written, signed, and dated request. The revocation will not apply to action taken prior to that date.

To Complete this Application:
Please make sure you have completed the entire application, uploaded supporting documentation, and e-sign this application (below).
Please type your first, middle, and last name below to show you have read and understand this information, and that you agree to submit documentation along with this application.
Date*

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Signature*

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