Reasonable Accommodation Request Form for Students with Disabilities

Reasonable Accommodation Request Form for Students with Disabilities

Midwest Institute does not discriminate on the basis of disability status in admission or access to its programs and activities. Future students of Midwest Institute must notify the college in advance if special accommodations are needed so that these arrangements can be discussed with the Education Department. Requests for reasonable accommodations are based on mutual planning among the Director of Education, staff, and faculty. The arrangement of reasonable physical and academic accommodations take time and may require follow-up interviews. Please submit your request at the earliest possible date.
Requestor
Date

MonthDayYear
Date
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Need for accommodation:
Please attach documentation of diagnosed learning disability: (diagnosis must be within the last 36 months)

Browse Files

Cancelof
Requestor's suggested accommodation:
Suggested accommodation by other agency or individual:
Midwest Institutes accommodation plan:
Request received by:

First NameLast Name
Date

MonthDayYear
Date
Form will be submitted to Mrs. Pandolfo, Director of Education, Midwest Institute

4260 Shoreline Dr, Earth City, MO 63045 Phone: (314) 344-4440 Fax 314-344-0495

You will be contacted regarding accommodation decision within 5-7 business days after submission
For Internal Purposes Only - Do Not Write Below this Line
I concur with the proposed accommodation:
Student Signature
Date

MonthDayYear
Date
I wish to appeal the committee's proposal:
Date

MonthDayYear
Date
Accommodation Approved:
Director of Education
Date

MonthDayYear
Date
Accommodation Approved:
Director
Date

MonthDayYear
Date
Should be Empty: