Special Accessibility and Accommodations Request Form 2: Mobility Impairment

Special Accessibility and Accommodations Request Form 2: Mobility Impairment

Please fill out this form and email the completed word document to Lisa Bierre, ADA Coordinator/Learning Specialist, . Also attach documentation from a licensed health care provider.

For additional instructions and background information, see the Accessibility and Accommodations General Information document on the CLC SharePoint site.

Note: This form will be forwarded to the Chairperson of the Unity College ADA Task Force. The Chairperson of the Task Force will then communicate with the student making the request to determine reasonable accommodations.

Questions should be addressed to:

Lisa Bierre, ADA Coordinator/Learning Specialist

Phone: (207) 509-7626

Fax: (207) 512-1177

CLC 120, Unity College

90 Quaker Hill Rd. Unity, ME 04988

Student Information:

Name:

Telephone (Home):

Telephone (Mobile):

Email:

Current address (If living off campus, or accepted, but not yet attending Unity College):

Accommodations requested for: Semester (Fall/Spring): Year_____

Today’s Date:

What is the nature of your mobility impairment? (please be specific)

What specific accommodations related to your on-campus activities are you requesting?

Unity College will make reasonable accommodations when possible. The College cannot make accommodations, however, that place an unreasonable financial hardship on the institution or that fundamentally alter the academic programs.

Electronic Submission Process

The student submitting this form agrees to the following:

Place an X if you agree to the below stipulation

______I submit this disclosure of my disability and application for accommodations with the understanding that it is completely voluntary. I understand that by submitting this form and typing my name below, this information may be shared on a need to know basis with appropriate Unity College faculty and staff including but not limited to my academic advisor, my instructors, and the staff of the CLC for use in understanding my needs and planning for appropriate support services.

Please type your name as an electronic signature and then send the completed word document to Lisa Bierre, ADA Coordinator/Learning Specialist,

Name______

Note: This release statement is not a Family Educational Rights and Privacy Act (FERPA) release form and does not apply to releasing information to third parties not employed at the college.Contact The Unity College Registrar’s Office in Founders Hall for more information on FERPA.

- Revised 10/2017 ldb