Student Accommodation Request

Student Information

Please enter your information

First Name

Middle Name

Last Name

Student ID (S-Number)

Major

Phone Number

Date of Birth

AUM Email

Please use your university issued email address

Address

City/State

Zip Code

Referral Source

Are you working with a VR or VA counselor?

Specific Accommodation Information

My diagnosed disability falls into the following category

Specific Diagnosis

Duration

Secondary Disability or Disabilities

Secondary Diagnosis or diagnoses

Accommodations Received in the past

Accommodations Requested

When would you like to begin receiving accommodations? (List the semester and year i.e. Summer 2020)

Emergency Contact Information

Emergency Contact Name

Emergency Contact Relationship

Emergency Contact Address

Emergency Contact City/State

Emergency Contact Zip Code

Emergency Contact Phone Number

Emergency Contact Email

Upload supporting document(s)

Please click here for our documentation criteria.

If you you have any documentation with the last 2 years, please upload that, as it may suffice rather than having to complete all the requirements noted in the documentation criteria. Please follow up with CDS regarding documentation: cds@aum.edu.

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