Reasonable Accommodation Verification Form
for College Dietary Plan

Lynchburg College Disability Services works with students to provide accommodations for dietary needs related to medical disabilities in compliance with Section 504 of the Rehabilitation Act of 1973, The Americans with Disabilities Act of 1990 (ADA), and the ADA Amendments Act of 2008 (ADAAA). ADAA defines disability as a physical or mental impairment that substantially limits one or more major life activities. Under this definition, an impairment is a disability if it substantially limits the ability of the person to perform a major life activity as compared to the average person in the general population.

Lynchburg College provides reasonable accommodations to students with disabilities who have a verifiable need for the reasonable accommodation. A reasonable accommodation is an exception to the usual rules, policies, practices, or services that a resident with a disability may need to have an equal opportunity to use and enjoy College dining services. The Disability Accommodations Request Form for College Dietary Plan authorizes you to provide the information requested on this form.

PLEASE REVIEW THE ENCLOSED REASONABLE ACCOMMODATION REQUEST FORM THAT EXPLAINS THE STUDENT’S REQUEST FOR REASONABLE ACCOMMODATION AND THEN ANSWER THE FOLLOWING QUESTIONS:

1.  Does the student have a disability under this definition? ______Yes ______No

2.  Please identify the student’s impairment(s) and describe how each impairment substantially limits her/her ability to perform a major life activity as compared to most people in the general population:

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3.  Please identify if the student is using any measure(s) (e.g., prescriptions, treatment, therapy, etc.) that mitigates the limitations caused by his/her impairment and, if so, if the mitigating measure(s) eliminates the substantial limitations:

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4.  Please explain how the accommodation is necessary for the resident to use and enjoy the College Dining Plan as compared to a person without a disability:

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5.  Please identify any other accommodation(s) that may be equally effective in allowing the resident to use and enjoy College dining services:

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Please provide contact information, sign and date this questionnaire (below), and return it to:

Julia Timmons, Disability Services Coordinator
Academic Achievement Center
Lynchburg College
1501 Lakeside Drive
Lynchburg, VA 24501
Fax: 434-544-8808
Email:

Provider Contact information

Name: ______

Address: ______

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Telephone: ______

FAX and/or Email address: ______

Professional Signature: ______

License #: ______

Date: ______

Julia R. Timmons, Disability Services Coordinator Eff. October 2017