Disability Notification and Accommodation Request

Please submit this online form to the JIU Director of Disabilities Services. Alternatively, you may type or print information and return it via fax to 303-784-8457 or by email to disabilities@international.edu. Information contained on this form is confidential to the extent permitted by law. Your accommodation request will be processed only when the requested medical documentation has been received by JIU. Please print or type your responses below, and submit additional information as necessary to disabilities@international.edu or by fax to 303-784-8457, attention: Director of Disability Services.

Personal and Confidential

Salutation:

Mr.

Mrs.

Ms.

Dr.

First Name: *

Last Name: *

Street Address 1: *

Street Address 2: *

City or Town: *

State or Province:

Zip or Postal Code: *

Daytime Telephone Number: *

Email Address: *

My disability - diagnosis and description: *

Describe in your own words limitations caused by the condition you have named.: *

Note: Medical documentation of these limitations must be provided to complete this request.

Describe how the accommodation will enable you to complete the application process or to be successful as a student.: *

The undersigned individual certifies to the truth and accuracy of the above information. Submitting this statement with individual's name and email typed below constitutes the individual's signature.

First and Last Name: *

Email Address: *

Dated:

If you have additional comments, please use the space below:

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