Living and Learning Accommodation Application

The accommodation application must be completed for each academic year.

* indicated required fields

Request for Accommodation

*Application Type:

*Academic Year for Accommodations:

Contact Information

*First Name:

Middle Initial:

*Last Name:

Preferred Name:

*Birthdate:

*919#:

*Northwest Email:

*Cell Phone:

Emergency/Other Phone:

Local Address

*Street Address:

*City:

*State:

*ZIP Code:

Permanent Address

Street Address:

City:

State:

ZIP Code:

Academic Profile

*Preferred Learning Style:

*Major:

*Advisor:

*Information Release:
Accommodation information be shared or discussed with other Northwest departments and your parents.

Specifications

*Describe your diagnosed disability.

*What accommodations has your medical professional prescribed?

*Have you received any accommodations in the past at Northwest? Yes
No

*What accommodations have you received?

*What academic years have you received accommodations at Northwest?

What assistive technology to you use?

***** ALERT *****

Before your application is considered complete, you must send an email to ada@nwmissouri.edu with your medical or counseling professional’s supporting documentation including accommodation recommendations (on their letterhead and signed).

Please enter your initials in the Signature field below which constitutes your intent and authorization to submit the accommodations application.

*Signature (enter initials):

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