Request for Services & Accommodations

Name

First NameLast Name

Preferred Name

First NameLast Name

Email

example@example.com

Personal Pronouns

Date of Birth

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please state your specific disability(ies).

Please describe how your disability might affect your ability to access classes and/or the campus at Stephens College.

Please list the reasonable accommodations you are requesting in as much detail as possible. (Please note that the College may not be able to provide the specific accommodation you request, but may be able to provide a different accommodation to provide access.)

Please Upload ADA Documentation.

For students only: Please select one.

For the semester and year above, I wish to have my academic advisor and semester instructors and/or (if applicable) res life staff informed of my accommodations. For testing accommodations (if applicable), I understand that I must give both my instructors and the Student Success Center at least three business days prior notice for exams. Failure to do so may hinder my ability to access testing accommodations.

For students only: If in the event of a residence hall evacuation (e.g., fire, tornado, etc.), you wish to have Student Development and Safety & Security informed of a physical/medical disability, please email adacoordinator@stephens.edu. (Please note, Stephens College employees and residence hall staff are not necessarily trained to administer first aid (e.g., CPR, epi-pen administering, cortisol pen administering, etc.). If you have a medical diagnosis that you wish for Boone County 911 medical personnel to be aware of, please register for Smart 911 at smart911.com.)

Questions regarding this form and/or the College’s ADA Policy should be directed to the ADA/Section 504 Coordinator.

Email: adacoordinator@stephens.edu
Phone: (573) 876-7240

1200 E. Broadway
Campus Box 2111
Columbia, MO 65215

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