ADA Application for Special Accommodations

NORTHWESTERN OKLAHOMA STATE UNIVERSITY
709 OKLAHOMA BOULEVARD, ALVA, OK 73717
DISABLED STUDENT SERVICES
FINE ARTS 126
580-327-8414

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RELEASE OF INFORMATION I give permission to the Coordinator of Disabled Student Services to request reasonable, appropriate or necessary academic accommodations for me. This is based on the disability I stated above. This information is to be kept confidential between the instructor, the Coordinator of Disabled Student Services, appropriate staff, and myself. I also give permission to the Disabled Student Services Coordinator to request that all medical information regarding my physical, mental or learning disability be released to the following person: Mr. Calleb Mosburg American with Disabilities Coordinator Northwestern Oklahoma State University Alva, OK 73717

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Northwestern Oklahoma State University

709 Oklahoma Blvd., Alva, OK 73717
Phone: (580) 327-1700

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University. All Rights Reserved.

Mission Statement

Northwestern Oklahoma State University provides quality educational and cultural opportunities to learners with diverse needs by cultivating ethical leadership and service, critical thinking and fiscal responsibility.

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