Accommodations Initial Intake Form | Presbyterian College

Student's Name:*

First Last

PC Student ID #:*

PC Email:*

Student's Cell Phone #:*

Student's Home Address:*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

SECTION I. Types of Requested Accommodations

Please check all the accommodations you are requesting.

Types of Requested Accommodations*

Academic
Housing
Meal Plan
Physical Campus

SECTION II. Declared Disability

The Office for Civil Rights defines a person with a disability as, “a person with a physical or mental impairment that substantially limits a major life activity; has a record of such an impairment; or is regarded as having such an impairment. The determination of whether a student has a physical or mental impairment that substantially limits a major life activity (and therefore has a disability) must be made on a case by case basis.”

Select all that apply.

󠄀 Attention Deficit/Hyperactivity Disorder (ADD/ADHD)
Autism Spectrum Condition/Disorder
Chronic Medical Condition
Deaf or Hard of Hearing
Learning Disability
Physical/Mobility
Psychological
Visual Impairment

SECTION III. Accommodation Requests

Select the reasonable academic accommodations that you believe will provide you with equal access to education, housing, meal, or co-curricular activities at PC. (Equal access is defined by the U.S. Department of Education as an equal opportunity of a qualified person with a disability to participate in or benefit from educational aid, benefits, or services.). Indication of these accommodations does not necessarily mean these are the accommodations you will receive.

ACADEMICS:

Select all that apply.

If "Other" was selected, please describe:

HOUSING/MEALS:

Select all that apply.

Single Room
Single room with private bathroom

(Single rooms are determined on a case-by-case basis and limited by room space availability). Students with disabilities or medical conditions are assigned roommates in the same manner as other housing applicants unless the need for a single room is identified as a reasonable accommodation or medical necessity and one is available at the time the student’s housing application is processed. It is recommended that students submit the Accommodations Initial Intake Form and appropriate medical documentation as soon as possible to ensure a proper room accommodation).
ADA accessible room (including bathroom)
First-floor room
Emotional Support Animal (Emotional Support, Comfort, Companionship, or Therapy animal)
Service Animal (The Department of Justice (“DOJ”) and the ADA define a “service animal” as “any dog that is individually trained to do work or perform tasks for the benefit of an individual with a disability, including a physical, sensory, psychiatric, intellectual, or other mental disability”. The DOJ is explicit that emotional support, comfort, or companionship animals are not considered service animals under the ADA.
Dietary restriction(s) or Food Allergies
Other
NOTE: Returning students who need this accommodation for a future semester or school year MUST submit an Authorization of Accommodations Form prior to the priority housing application deadline as set by the Office of Residence Life. The Academic Success Office will then notify Residence Life of this request.

If "Other" was selected, please describe:

SECTION IV. Outside Agency Support

Select any of the following outside agencies from which you are currently receiving support.

OUTSIDE AGENCY SUPPORT:

Select any of the following outside agencies from which you are currently receiving support.

Vocational Rehabiliation
Services for the Deaf and Hard of Hearing
VA
Other
Not applicable

If "Other" was selected, please describe:

SECTION V. Signature

Disability-related information is protected by the Buckley Amendment. Information will not be released or discussed without student’s expressed written consent except to College officials and faculty having legitimate educational interests and on a need-to-know basis. Students, by submitting this Accommodations Initial Intake Form, you are providing your electronic signature consent for the Accessible Education Office to share this information with College officials and faculty, as stated.
I understand that my electronic signature affirms that I am registering with the Presbyterian College Accessible Education Office as a student with a documented disability as defined by the Americans with Disabilities Amendments Act and Section 504 of the Rehabilitation Act. I understand that despite my disability,
1. I must meet the minimum standards as set forth by my program of study, with or without accommodations, keeping in mind that instructors are neither expected to compromise the essential course requirements nor to fundamentally alter a course.
2. I am responsible for following Presbyterian College’s policies as outlined in the Arts and Sciences Academic Catalog, The Garnet Book, and the Blue Book.
3. I must complete and submit an Authorization of Accommodations Form to the Accessible Education Office for each semester that I am enrolled and intend to receive the approved accommodations. Doing so provides the Accessible Education Office permission to provide my Accommodations Approval Form to my professors and/or Office of Residence Life. (This is not automatically done for me.) Instructors are not responsible for implementing immediate accommodations when students wait until the last minute to complete their Authorization of Accommodations Form.
4. It is my responsibility to discuss my approved accommodations with each of my instructors.
5. In addition to this form, diagnostic documentation from a healthcare provider must be received in order for my file to be reviewed for accommodations.
6. I understand that I must participate in the structured exchange process with the Accessible Education Coordinator

Student's E-Signature:*

Today's Date*

mm/dd/yyyy

ABOUT

Admission

Academics

Campus Life

Giving

Request for Services

Accommodations Initial Contact Form

SECTION I. Types of Requested Accommodations

SECTION II. Declared Disability

SECTION III. Accommodation Requests

SECTION IV. Outside Agency Support

SECTION V. Signature

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