Request for Housing Accommodations

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

Completing this Request for Disability Housing Accommodations is the first of three steps to register with Disability Services:

Complete this form, the Request for Disability Housing Accommodations
Provide documentation of your disability
Complete an intake meeting with Disability Services the first week of classes (or whenever you register)

Please use this form to request the housing accommodations you may need at Western Colorado University.
If you need assistance completing this form, please call or email Disability Services: 970-943-7056; disability@western.edu

This form is to be completed by the student.

Contact Information *This question is required.

Today's Date (Please use MM/DD/YY format) This question requires a valid date format of MM/DD/YYYY.

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First Name

Last Name

Preferred Name (Optional)

Western Student ID

Date of Birth This question requires a valid date format of MM/DD/YYYY.

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Cell Phone

Address

City

State

Zip

Western Email Address
Please note: Your Western email address is the official form of communication from Western. Please include it and check it on a regular basis. This question requires a valid email address.

Other Email Address This question requires a valid email address.

Please specify your gender below if you have answered "other" to the previous question.

2. What is your student status (classification)?