Washburn University Student Accommodation Request

* indicates a required field

Welcome to Washburn!

PLEASE READ BEFORE COMPLETING THIS FORM:Required *

This form should only be completed by the STUDENT themselves, not a representative of the student (i.e., parent, guardian, teacher, counselor, therapist, etc.). I certify that I, the person completing this form, am the student requesting accommodations through Washburn University/Washburn Institute of Technology/Washburn University School of Law.

Yes

General Information

Term/Semester Required *

Please select the semester you are requesting the accommodations be applied to.

Term/Semester Spring 2025 Term/Semester Summer 2025 Term/Semester Fall 2025

Campus LocationRequired *

Campus Location Washburn University Campus Location Washburn University-Law School Campus Location Washburn Institute of Technology

Student Requesting Accommodation

First NameRequired *

Last NameRequired *

Middle Name

Preferred Name

Gender

Washburn ID Number (WIN) Required *

Cell Phone NumberRequired *

Washburn EmailRequired *

Please use your university issued email address. It is your first and last name. Example: john.smith@washburn.edu

Questions

Please select all areas that impact you:Required *

Learning (example: dyslexia, dysgraphia, dyscalculia, ADHD, etc) Mental Health (example: anxiety, depression, bi-polar, PTSD, etc) Physical (example: visual, hearing, mobility device, etc) Temporary Injury/Condition Other No Diagnosis

Are you currently taking any medication(s) related to your disability?Required *

Are you currently taking any medication(s) related to your disability? Yes Are you currently taking any medication(s) related to your disability? No

Please list current medication(s): Required *

Have you received accommodations in the past?Required *

If yes, please indicate in which setting (i.e., high school, previous college, workplace, etc.). If no, please write NA

What disability related accommodations are you requesting?Required *

What disability related accommodations are you requesting at Washburn University/Washburn Tech/Washburn University School of Law (examples may include extended test/exam time, distraction reduced environment, note taking assistance, etc.)? If you are unsure about what accommodations might be helpful or what accommodations you might be eligible for, please indicate in the box, and we will discuss details in your welcome meeting.

Are you requesting Accessible Residential Living (includes Room Modifications, ESA, or Meal Plan Exemptions)?Required *

Are you requesting Accessible Residential Living (includes Room Modifications, ESA, or Meal Plan Exemptions)? Yes Are you requesting Accessible Residential Living (includes Room Modifications, ESA, or Meal Plan Exemptions)? No

Please provide additional information regarding your request.Required *

*ESA Request-please describe the animal you are requesting be your ESA animal including type of animal and color*

Will you be living on campus or off campus?Required *

If living on campus, please list your dorm name (i.e., Lincoln, LLC, or the Village).Required *

If you selected Meal Plan Exemption, please indicate if the request is also for religious reasons:Required *

If you selected yes, please contact our Title IX/ADA Coordinator at 785-670-1509.

Yes No

Please describe in your own words the way(s) that your disability/disabilities impact you:Required *

Be as thorough as possible. Please do not copy/paste from documentation or state “see documentation”. Focus on Academics (i.e., reading, writing, math, note taking, executive functioning, etc.)

Please select any of the following areas that are impacted by your disability:Required *

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If there is anything you would like us to know that was not addressed on this form, you may tell us here:Required *

Please write NA if you have nothing to add.

Upload supporting document(s)

Please review our Helpful Documentation Guidelines for examples of types of documentation that can be submitted for review.

https://www.washburn.edu/studentaccessibility/files/helpful-documentation-guide.pdf

*Disclaimer prior to submitting request located at the bottom of the form:

I am voluntarily self-identifying as a person with a disability and I am submitting this form to begin the interactive process per the ADA/ADAAA. I understand that accommodations are not provided until approved. I understand that all of the requested accommodations may not be reasonable, and therefore may not be approved. I understand that I should discuss the accommodations with the faculty member who will provide them.

Document Information

Document Title

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Description