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Public Accommodation Request
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Student Information
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First Name
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Last Name
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Middle Name
Germanna Student ID
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Germanna Email
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Please use your university issued email address
Secondary/Alternative Email
Student Cell Phone Number
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Parent or Guardian Phone Number & Email
Is English your first language?
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Is English your first language?
Yes
Is English your first language?
No
What is your native language?
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Did you graduate high school in the United States?
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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?
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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 due to disability?
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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.
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Document Information
Document Title
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Maximum file size: 10240kb
Description