Lafayette College Accommodation Request

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Student Information

Please enter your information

First Name

Last Name

Middle Name

Preferred Name

Student ID (LNumber)

Lafayette Email Address

Please use your university issued email address

Phone Number

Preferred Pronouns

Please check reason for request:

Primary Disability

Secondary Disability(ies)

In your own words, please describe how your disability(ies) impacts your daily life and education:

How long have you been treated with this/these disability(ies)?

Are you active in any form of treatment? If yes, what kind and how often?

What type of accommodations are you requesting? Select all that apply.

Please list the accommodation(s) you are requesting.

Please describe how the accommodation(s) will reduce the impact of your disability(ies).

Describe if there is a barrier to access

Is there any other information you would like to provide?

Student Signature

Date

Upload supporting document(s)

When uploading documentation, please use the following format to name the document

Student Last name_Student First name_Name of Document_Month_Day_Year