STUDENT ACCOMMODATIONS REQUEST FORM
Request for Accommodations for:
Student's Name
*
First Name
Last Name
Student's Email Address
*
Requested by:
Your Name
*
First Name
Last Name
Your Email Address
*
Your Organization:
*
Please select the requested accommodation(s) from the list below:
Accommodation options:
Double time
Text-to-speech
Separate room
Logistical provisions (e.g., low lighting, white noise)
Preferential seating
Other (describe below - a field will appear if you select Other)
Please select the type(s) of supporting documentation that you have from a physician or other qualified professional reflecting a diagnosis of the candidate’s disability and an explanation of the accommodation(s).
Type(s) of documentation:
Medical Diagnosis
Individualized Education Plan (IEP)
Description of Diagnosis
Please note that the RISE Up team reserves the right to request that you provide copies of documentation.
Submit
Should be Empty: