Student Access Office

Student Access Office Forms

Accommodation Request Form

Name *

Student ID # *

Email Address *

Permanent Home Address *

Campus or Local Address *

Phone *

Cell Phone *

Emergency Contact Name *

Emergency Contact Phone # *

I am requesting services for (year): *Enter the year you would need services

Term *

FallSpringSummer

I am a *

Undergraduate StudentGraduate StudentAdult Undergraduate StudentOther

Please Specify "Other" *

I am a (check one): *

first time Student Access Office accommodation recipient. returning Avila student and I have previously submitted the necessary documentation.returning student with previously submitted documentation, but I have additional documentation I would like to have added to my file (attach copies) OR am requesting a change in my accommodations.

Upload additional documentation to be added to your file.

No file chosen

I have (check one): *

enrolled for my classes (advise our office immediately if you change your schedule.)not yet enrolled for my classes, but I will enroll on or before (add date below)I understand that it is my responsibility to notify the Student Access Office when I enroll. I also understand that late enrollment may delay the fulfillment of my request.

Registration Date for classes

If you have not enrolled yet, when will you enroll?

Accommodations Requested *Please be as specific as possible, noting for which courses the requested accommodations are needed):

The information contained in this form, and in any attachments, is true and accurate to the best of my knowledge.

Type Your Name as your Signature *

Date *

I agree to allow the release of my name and contact information to notetaker(s) assigned to my classes if this is an approved accommodation for the indicated semester. In addition, I agree to allow the release of my name and contact information for the purpose of securing alternative textbook formats if this is an approved accommodation for the indicated semester.

Type Your Name as your Signature *

Date *

Student Information Form

First Name *

Middle Name

Last Name *

Date of Birth *

Student ID#

Major *

Email Address *

I am currently receiving information/assistance from:

Division of Vocational Rehabilitation Bureau for the BlindU.S. Department of Veterans AffairsAvila University Financial AidOther (Please Specify)

State Name

Other (Please Specify)

Name of counselor/agency contact:

Phone

Date of most recent documentation of disability

Type of Disability *

Doctor's Name

Phone

Emergency Contact Name *

Phone *

The information contained in this form and any attachments are true and accurate to the best of my knowledge.

Type Your Name as your Signature *

Date *

I hereby authorize release to Avila University information concerning my disability and educational/vocational history for the purposes of providing me with services. I understand that the information obtained by Avila University will be held in the strictest confidence and not be released directly or indirectly without written consent except for the purpose of providing services.

Type Your Name as your Signature *

Date *

Interpreter Request Form

First Name *

Last Name *

StudentEmployeeGuest/VisitorOther

If other, please indicate:

What Date Will You Need the Interpreter (MM/DD/YYYY)? *

Select the Starting Time for the Interpreter (i.e. 8:00 a.m.): *

Select the Ending Time for the Interpreter: *

Location: *

Building: *

Room: *

Request Type *

Class RequirementExtracurricular ActivityStudent/Advisor MeetingCall/TeleconferenceExam/QuizPersonnel MeetingTutoringVideo/Recorded PresentationPerformance/PlayOther Meeting or Event

If Other Meeting or Event, Please Specify:

Event Contact Person's First Name *

Event Contact Person's Last Name *

Event Contact Person's Phone Number *

Please specify how you wish to communicate with the person (e.g., American Sign Language, Transliterating, Oral):

Additional Information or Details:

All requests must be returned to the Student Access Office (SAO) as far in advance as possible, but at least five (5) business days prior to an event (requests submitted after that time will be filled as interpreters are available). Changes and cancellations of requests should be made at least two (2) business days prior to an event. Failure to notify the SAO of a change or cancellation may result in a delay or inability to provide interpreting services.

I acknowledge that before requesting accommodations I have read, understand, and agreed to comply with the policies pertaining to interpreter services of Avila University. I agree to report immediately to the SAO any schedule changes, room changes, or problems that arise.

Type Your Name as your Signature *

Today's Date *

Grievance Form

First Name *

Last Name *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Phone (Home) *

Phone (Work)

What is the most recent date you experienced disability harassment or discrimination? *

If this date is more than 10 days ago, please explain the purpose for your delay in filing this grievance

When, and in what way, did you first become aware that the treatment, act, or decision represented disability harassment or discrimination? *

Have you tried to resolve your grievance through other channels? If yes, please explain. *YesNo

Type Your Name as your Signature *

Today's Date *