Newlane ACADEMIC ACCOMODATIONS Request Form

Academic Accommodations Request
Request Submission Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Student Name:

First NameLast Name
Student Email:
Provide an email account that is regularly checked.
Student Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Student's Degree Program:

DISABILITY/DIAGNOSIS LIST: List all diagnoses related to this request as well as the approximate year the diagnosis was confirmed and the type of practitioner that made the diagnosis.

Rows	Diagnosis/Disorder	Diagnosed By	Year of Diagnosis
Diagnosis #1
Diagnosis #2
Diagnosis #3
Diagnosis #4
Diagnosis #5
Diagnosis #6
Diagnosis #7
Diagnosis #8
Diagnosis #9
Diagnosis #10

ACADEMIC ACCOMODATIONS NEEDS DESCRIPTION: Briefly describe how your disability/diagnosis(s) limits your ability to complete assignments, assessments, etc., or otherwise limits your ability to participate in Newlane services, programs, or activities.
PREFERRED ACCOMODATIONS: Describe suitable accommodations that have been made by educational institutions in the past or preferred accommodations that would facilitate your ability to complete assignments or assessments, or otherwise participate in Newlane services, programs, or activities.
ADDITIONAL REQUEST INFORMATION &/OR DETAILS (OPTIONAL): Provide any further information that may help Newlane make a decision regarding whether to make accommodations, and how Newlane can best provide accommodations.

SUPPORTING DOCUMENTATION: Please upload documentation of your disability from an appropriately licensed professional.

Multiple files accepted. Maximum File Size: 10854KB
Cancelof

By submitting documentation in support of a disability accommodation request, you acknowledge and agree that the information provided will be used solely for the purpose of evaluating your eligibility for reasonable accommodations in accordance with applicable disability laws, including the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973.

All documentation and personal information will be kept confidential and will only be shared with individuals directly involved in the accommodation review process.

Please ensure that the documentation you submit accurately reflects your current condition and supports your request for reasonable accommodations. Submitting false or misleading information may result in a denial of accommodations or other appropriate actions in accordance with institutional policies.

If you have any questions regarding this form or the accommodation process, please contact accessibility@newlane.edu.
Acknowledgement Signature
Acknowledgement Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Academic Accommodations Request