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Confidential Request Form
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Student Information
Please enter your information
First Name
Required
*
Chosen Name
Chosen Name
Last Name
Required
*
Middle Name
Required
*
Student ID
Required
*
Please enter only 7 digits of your ID, this should include one leading 0. i.e. 0123456
Carlow Email
Required
*
Please use your university issued email address
Alternate Email
Cell Phone Number
Required
*
Permission to Leave a Voicemail
Permission to Leave a Voicemail
Yes
Permission to Leave a Voicemail
No
Physical Address
Required
*
Where you live when you are not on campus
Which campus site are you attending?
Required
*
Greensburg
Cranberry
Oakland (main Campus)
Status/Year in School
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*
First Year
Sophomore
Junior
Senior
Graduate
Adult
non-traditional
Transfer student
Major:
Required
*
if you are deciding, please write deciding
Name of your current Academic Advisor
Date of birth
Required
*
January
February
March
April
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December
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Specific Accommodation Information
Do you have now/or have a history of disability documented by a licensed medical provider?
Required
*
Do you have now/or have a history of disability documented by a licensed medical provider?
Yes
Do you have now/or have a history of disability documented by a licensed medical provider?
No
Are you requesting an assessment for a possible disability at no charge to you?
Are you requesting an assessment for a possible disability at no charge to you?
Yes
Are you requesting an assessment for a possible disability at no charge to you?
No
Do you have an IEP or 504 plan in High School?
Required
*
Do you have an IEP or 504 plan in High School?
Yes
Do you have an IEP or 504 plan in High School?
No
Please provide the dates of the IEP or 504 plan
How does your disability affect you academically?
Required
*
How does your disability affect student life in general, like taking tests and studying?
Required
*
If your disability does not affect you in student life in general. please write NA
Are you requesting an accommodation for housing?
Are you requesting an accommodation for housing?
Yes
Are you requesting an accommodation for housing?
No
If yes, please describe your request:
Are you requesting an accommodation for dining?
Are you requesting an accommodation for dining?
Yes
Are you requesting an accommodation for dining?
No
If yes, please detail your request:
Have you received accommodations at Carlow University or other institution of Higher Learning in the previous four years?
Have you received accommodations at Carlow University or other institution of Higher Learning in the previous four years?
Yes
Have you received accommodations at Carlow University or other institution of Higher Learning in the previous four years?
No
If yes, where have you received accommodations?
Upload supporting document(s)
Do NOT upload IEP or 504 plans unless it includes: diagnosis, functional limitations, suggested accommodations
How did you hear about Disability Services Office (DSO)?
Faculty Referral
Syllabus Statement
Counseling Referral
Nurse Referral
Athletic Training Referral
Adviser Referral
CTC Presentation
Orientation
Other
Website
If other, please describe how you heard about DSO?
Document Information
Document Title
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File
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