Special Accessibility and Accommodations Request Form 3:

Academic Accommodations

Please fill out this form and email or return the completed document to Lisa Bierre, ADA Coordinator/Learning Specialist at . Students should also provide medical documentation from a licensed health care provider, and any other supporting documentation.Documentation may be sent through U.S. Mail, as a scanned email attachment, or by fax. All correspondence is processed with careful consideration of privacy rights. For requests requiring additional medical documentation, Unity College provides a standard health care provider form available on the CLC SharePoint siteor upon request. Students should forward the health care form to their health care provider; the health care provider should return the form to Lisa Bierreby US mail, fax, or email (see below.)

For more information, see “Accessibility and Accommodations General Information” available on the CLC SharePoint site or upon request. It is the student’s responsibility to consult with the ADA Coordinator after submitting this form.

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

Accommodations Requested For: Semester (Fall/Spring): Year:

Today’s Date:

Please explain the nature of your disability and how the disability impacts your academic performance or your participation at Unity College:

Your eligibility will be determined by the diagnostic assessment materials that you provide, along with medical documentation from a licensed health care provider. Documentation should be as current as possible. The college does not provide diagnostic assessment. The ADA Coordinator/Learning Specialist will gather all pertinent information and determine appropriate strategies. In certain circumstances, the ADA Coordinator might seek the advice of the Student Support Team or other appropriate staff/faculty.

Check reason(s) for requesting academic accommodations:

☐ Learning Disability☐ Mobility Impairment

☐ ADHD☐ Medical Condition

☐ Psychological Condition☐ Other (Specify):

☐Sensory Impairment (hearing, vision, etc.)

Please check any services that you believe would be appropriate and helpful:

☐ Extended time for examinations ☐ Classroom note-taking assistance

☐Exams taken in CLC or quiet location ☐ Textbooks in audio or digital format

☐Interpretation of exam questions ☐ Individual or small-group tutoring

☐Tests read or scribed ☐ Other (Specify):

☐ Assistive Technology (Specify):

Please provide below any additional information you feel would help the Learning Specialist, your advisor, or instructors understand and plan for your needs:

Electronic Submission Process:

The student submitting this form agrees to the following:

Place an X if you agree to the following 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 tomy 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 at

Name______

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 10/2017ldb