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Public Accommodation Request
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Student Information
Please enter your information
First Name
Required
*
Last Name
Required
*
Middle Name
Germanna Student ID
Required
*
Germanna Email
Required
*
Please use your university issued email address
Secondary/Alternative Email
Student Cell Phone Number
Required
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Parent or Guardian Phone Number & Email
Is English your first language?
Required
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Is English your first language?
Yes
Is English your first language?
No
What is your native language?
Required
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Are you enrolled in our Summer Program?
Required
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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
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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
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Are you a DE/IDE or Early College student?
Yes
Are you a DE/IDE or Early College student?
No
Please select the location where you are taking your college courses
Required
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Please select the location where you are taking your college courses
I am taking college classes at my high school
Please select the location where you are taking your college courses
I am taking college classes on one of the Germanna campuses or online
Did you graduate high school in the United States?
Required
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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
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Do you need support for tests and quizzes?
Yes
Do you need support for tests and quizzes?
No
Are you requesting accommodations for your classes?
Required
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Are you requesting accommodations for your classes?
Yes
Are you requesting accommodations for your classes?
No
My diagnosed disability falls into the following category
Required
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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.
Drop files here to upload
Upload File