Living and Learning Accommodation Application

The accommodation application must be completed for each academic year by the student.
The student must self-disclose any information regarding this accommodation request.
Please note: Northwest does not accept IEP or 504 plans as supporting documentation.

* 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: (if you haven't been assigned one, please enter n/a)

Personal Email:

*Cell Phone:

Academic Profile

* Class Standing:

*Major:

*Advisor: (if you haven’t been assigned an academic advisor yet, please enter n/a)

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

Specifications

*Describe your diagnosed disability.

*What accommodations are you applying for at Northwest?

*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?

* 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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