Disability Services Student Intake Form
In accordance with Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act, Iliff coordinates appropriate and reasonable accommodations and access for students with physical, cognitive or other disabilities. The School is committed to the provision of reasonable accommodations to qualified students with disabilities during their studies at Iliff.

Students must request accommodations and disclose his/her disability before any accommodation can be implemented. Students with disabilities who need accommodations are encouraged to identify themselves and submit a request via their academic advisor. In most cases, students will need to provide appropriate documentation of disability and/or information related to the student’s disability or functional limitations that substantiates requests for services. The Iliff School of Theology holds these requests and information private, and are not included in your academic records.

The Disability Services Team attempts to review requests and set up a meeting with the student within two weeks of receipt. Please review the Master Student Handbook for information regarding disability services at Iliff.

Email address
Personal Information
First Name
Your answer
Last Name
Your answer
Iliff ID Number
Your answer
Iliff email address
Your answer
Phone
xxx-xxx-xxxx
Your answer
D.O.B
Date of Birth (xx/xx/xxxx)
Your answer
Degree Program
Your answer
Matriculated
The first quarter enrolled at Iliff
Your answer
Graduation
Estimated Graduation Date
Your answer
Advisor
Academic Advisor
Your answer
Expectations for Documentation
Iliff’s policy on Disability Accommodations is stated in the Masters Student Handbook. In addition to the request for accommodations form, in most cases, students will need to provide appropriate documentation of disability and/or information related to the student‘s disability or functional limitations that substantiates requests for services.

Documentation must be current and must be from an appropriate professional, such as a physician, psychologist, LD/ADHD specialist, or other qualified professional. Appropriateness of documentation will be determined on a case-by-case basis. Documentation should, at a minimum, include the presenting problem and relevant history, information on current limitations and how these relate to the educational environment, and suggested educational accommodations with rationale for recommendations. If the submitted documentation is incomplete or does not support the student’s request for accommodations and/or services, the student may be asked to provide additional documentation. For example, an Individualized Education Plan, 504 Plan, or Summary of Performance from a previous academic institution without supporting information generally is not considered to be sufficient documentation. The cost of obtaining all documentation is borne by the student.


Documentation can be delivered by the student or can be sent directly to:

Advising Center
Iliff School of Theology
2323 E. Iliff Ave.
Denver, CO 80210-4798
advising@iliff.edu

At the discretion of the School, provisional accommodations may be made prior to the receipt of appropriate documentation.

Disability(ies) / Medical Condition(s)
Primary Disability/Medical Condition
(Check all that apply)
Required
Primary Disability
Please explain
Your answer
Secondary Condition
If applicable, please explain
Your answer
Temporary Disability/Medical Condition
If applicable, please explain
Your answer
Academic work
Please be as specific as possible and explain how your disability/ disabilities affects your academic work.
Your answer
Accommodations
Accommodations Previous
What accommodations have you previously used in an academic setting? If none, please indicate that in your answer.
Your answer
Accommodations Requesting
Please list and describe the accommodations and services you are requesting. Please be as specific as possible.
Your answer
Adaptive technology
If applicable, please list any adaptive technology you have used and/or are requesting to use.
Your answer
Medications
If applicable, please, indicate if you take any medications and/or experience side effects that may impact learning/concentration?
Your answer
Other Information
Additional Information
Sometimes knowing more about a student's background with help the Iliff Disability Team understand how best to accommodate a student. If you feel that will help guide us, please indicate any additional information that you would like to provide.
Your answer
Release of Information
I hereby give the Iliff School of Theology Disability Services permission to obtain and/or release information pertaining to my physical, mental or educational status. I understand that this is necessary in order to arrange accommodations such as auxiliary aids, services, and/or other assistance as per my request. I further give permission to Iliff Disability Services to release appropriate information about my disability to professors or other institutional personnel, for the purposes of education programming only. I understand that I may void this release at any time through written notice to Disability Services at Iliff.
Acknowledgement
Typing my name indicates my signature of release.
Your answer
Acknowledgement Date
(xx/xx/xxxx)
Your answer
Please complete the captcha before submitting the form.
Submit
Never submit passwords through Google Forms.
This form was created inside of Iliff School of Theology. Report Abuse - Terms of Service - Additional Terms