Request for Accommodations Form
Methodist College is committed to ensuring equal opportunity for qualified individuals with disabilities as defined by the Americans with Disabilities Act of 1990 (ADA), the ADA Amendments Act of 2008 (ADAAA) and Section 504 of the Rehabilitation Act of 1973.

Please note eligibility for services is based upon a review of current medical or psychological documentation and an initial intake interview. All information provided to the ADA coordinator is confidential.

The purpose of this form is to give you, the student, the opportunity to tell us about your disability, the impact of the condition, and what accommodations you have used in the past. The register process includes the following steps:
1. Submission of the Request for Accommodations Form
2. Initial intake interview and submission of disability documentation (if applicable)
3. Notification to instructors
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Name *
Full name
Date of Birth
MM
/
DD
/
YYYY
Email *
Phone number *
Program/Major *
Current year in school *
Required
Name of High School attended *
List accommodations received in high school or type N/A *
Name of previous college/university attended
List accommodations received at other colleges/universities or type N/A
What is the nature of your disability? *
Required
Do you take any medications that would affect your education? If yes, please explain:
Which major life activities are affected? Select all that apply. *
Required
In your own words, describe your disability and its impact on your daily life: *
Describe how your disability affects you in an academic setting: *
List the academic accommodations you are requesting: *
If requested, can you produce documentation from a qualified professional describing the nature of your disability? *
By typing my name I certify that the information provided is accurate and acknowledge that I am fully aware of my personal responsibilities as it relates to my request for disability accommodations. My failure to follow these guidelines may result in a delay or interruption of services. *
The ADA Coordinator will contact you ASAP to further discuss your request
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