Disability Disclosure and Accommodation Request Form

Please submit this form to request accommodation for a documented disability. This form should be submitted in addition to any documentation of disability, which should be mailed, emailed, or faxed to the Director of Disability Support Services. Please contact emyers@ehc.edu with any questions or concerns. This form should only be completed by current students and/ or admitted students who have deposited. This form is not necessary for emotional support animal applications. Please contact the Director of Disability Support Services for information about emotional support animals.

A note about confidentiality: Please note that this form will be submitted electronically and sent via email. Confidentiality of its contents may not be guaranteed. If you would prefer to complete paper copies of this form, please contact emyers@ehc.edu for electronic or hard copy versions.

Helpful terminology:

*Disability includes a physical or mental impairment that substantially limits one or more major life activities. Major life activities include such things as caring for oneself, performing manual tasks, walking, sitting, standing, lifting, reaching, seeing, hearing, breathing, learning, and working.

**Reasonable accommodations include modification(s) or adjustment(s) to the educational or residential environment of the college to enable a student to meet and perform requisite academic standards or to enjoy equal benefits and privileges of education or college housing.

All fields marked with asterisk (*) are required.

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Year*
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Did you receive special education services in high school?*
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Did you transfer from another college of university?*
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Are you a consumer of services from the Department of Aging and Rehabilitative Services or Bureau of Services for the Visually Impaired?*
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Do you request assistance in arranging for your reasonable accommodations?*
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If you request assistance in arranging for your accommodations, please select the semester for which you are requesting accommodations.
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Please type your full name and date.