ADA Application for Special Accommodations

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

Personal Information

Name *

Email Address (to receive a copy of this form) *

Phone Number *

Street Address *

City *

State *

Zip Code *

Classification *

Type of Disability *

Certified Professional's Information

First and Last Name of Certified Professional *

Certified Professional's Street Address *

City *

State *

Zip Code *

Certified Professional's Phone Number *

Social Security Number

This information will be for the purpose of determining reasonable, appropriate and necessary academic accommodations as this individual pursues his/her educational goals. *

Terms & Conditions

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

Check this box as your electronic signature.