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Request for Disability Accommodations (OLD FORM)

Welcome! We are excited to welcome you to Western as a Mountaineer!

Completing this Request for Disability Accommodations is the first of three steps to register with Disability Services:
  1. Complete this form, the Request for Disability Accommodations
  2. Provide documentation of your disability
  3. Complete an intake meeting with Disability Services the first week of classes (or whenever you register)
Please use this form to request the accommodations you may need at Western State Colorado University.
If you need assistance completing this form, please call or email Disability Services: 970-943-7056; arc@western.edu

This form is to be completed by the student.
Contact Information *This question is required.
This question requires a valid date format of MM/DD/YYYY.
calendar
This question requires a valid date format of MM/DD/YYYY.
calendar
This question requires a valid email address.
This question requires a valid email address.
Are you a Veteran?
Are you a client of the Veteran Administration of Vocational Rehabilitation?
Are you a client of The State Vocational Rehabilitation?
Describe how your disability currently impacts you in the following areas:
What accommodations are you requesting? (Include academic, physical, communication, access needs, etc.) *This question is required.
Space Cell AccommodationReason for Accommodation
1
2
3
4
5
Are you currently taking any disability-related medication?
Have you participated in any therapeutic services (therapy, coaching, support services, etc) to manage the impacts of your disability?
Western Academic Information
Prior School Information
Space Cell YesNo
Did you have an IEP, 504 Plan, or some other academic-based support in high school?
Are you transferring to Western from another college or university?
Please submit a copy of your IEP, 504 Plan, or other academic-based support.
Transfer Information
Academic Information
Informed Consent for Information Release
I (signed below) hereby authorize Disability Services at Western State Colorado University to discuss, either in writing or orally, my academic accommodations with appropriate administrators, instructors, professors, and third-party service providers as deemed necessary by Western Disability Services staff for the purpose of providing and/or coordinating accommodations and services for me.
If you are using a screen reader and cannot sign this electronically, you can sign a hard copy in the Disability Services office.
Clear
Signature of
Please attach your documentation here.
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