Special Accommodation Request Form
Student Information
You MUST have your documentation ready to upload before completing this form.
Name
*
First Name
Last Name
E-mail
*
example@example.com
Phone Number
*
Format: (000) 000-0000.
LSN Student ID
*
Specific Accommodation Information
My diagnosed disability falls into the following category
*
Please Select
ADD/ADHD
Learning LD
Psychological
Medical
Hearing
Visual
TBI
Autism Spectrum Disorders
Mobility
Other Physical
How does your disability affect you academically?
*
How does your disability affect student life in general, like taking tests and studying?
*
Please list the specific accommodations you are requesting. (Only listed accommodations will be considered)
*
Degree Enrollment Classification
*
Please Select
New Incoming Student
Current Student
What term is this request for
*
Upload supporting document(s)
*
Browse Files
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Document Title
*
Document Description
*
Submit
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