Public Accommodation Request

* indicates a required field

Student Information

Please enter your information

First NameRequired *

Last NameRequired *

Middle Name

Germanna Student IDRequired *

Germanna EmailRequired *

Please use your university issued email address

Secondary/Alternative Email

Student Cell Phone NumberRequired *

Parent or Guardian Phone Number & Email

Is English your first language?Required *

Is English your first language? Yes Is English your first language? No

What is your native language?Required *

Are you enrolled in our Summer Program?Required *

Are you enrolled in our Summer Program? Yes Are you enrolled in our Summer Program? No

Are you interested in learning more about our Summer Program?Required *

Are you interested in learning more about our Summer Program? Yes Are you interested in learning more about our Summer Program? No

Are you a DE/IDE or Early College student?Required *

Are you a DE/IDE or Early College student? Yes Are you a DE/IDE or Early College student? No

Did you graduate high school in the United States?Required *

Did you graduate high school in the United States? Yes Did you graduate high school in the United States? No

Do you need support for tests and quizzes?Required *

Do you need support for tests and quizzes? Yes Do you need support for tests and quizzes? No

Are you requesting accommodations due to disability?Required *

Are you requesting accommodations due to disability? Yes Are you requesting accommodations due to disability? No

My diagnosed disability falls into the following category

Identify Other Disability

How does your disability affect you academically? [to be completed by student]

What helps me to learn best? [to be completed by student]

Ie: assistive technology

Requested Accommodations:

Program of Study

Preferred Campus/Center

Fredericksburg (FAC) Locust Grove Campus (LGC) Daniel Technology Center (DTC) Barbara J. Fried Center (BJFC-Stafford)

Student Signature

Upload supporting document(s)

ie: IEP, 504 Plan, Psychological Evaluation, Medical Diagnosis, etc.

Document Title

FileRequired *

Maximum file size: 10240kb

Description