Living and Learning Accommodation Application

Request for Accommodation

*Application Type:
- Select - New Student Additional accommodation Annual renewal

*Academic Year for Accommodations:
- Select - 2020-2021 2021-2022 2022-2023 2023-2024

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:
- Select- Not Applicable Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

*ZIP Code:

Permanent Address

Street Address:

City:

State:
- Select- Not Applicable Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

ZIP Code:

Academic Profile

Preferred Learning Style:
- Select - Visual Auditory Verbal Physical

Major:
- Select -

*Advisor:

*Information Release:
Accommodation information  - Select - may may not  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):

To retain a copy for your records, print this page now.