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Student Information
Please enter your information
First Name
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Last Name
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Middle Name
Student ID
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Email
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Please use your college issued email address
Phone Number
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Specific Accommodation Information
My diagnosed disabilities fall into the following categories
If you selected Chronic Health above, please specify
If you selected Temporary Injury & Health Conditions above, please specify
These conditions could include temporary orthopedic conditions, concussions and temporary medical conditions. Temporary is lasting for only a limited period of time.
If you selected Other above, please specify
How and when was your disability diagnosed and documented?
Have you been tested and/or received a diagnosis in the past three years?
Have you been tested and/or received a diagnosis in the past three years?
Yes
Have you been tested and/or received a diagnosis in the past three years?
No
Are you requesting a medical accommodation?
Are you requesting a medical accommodation?
Yes
Are you requesting a medical accommodation?
No
Are you requesting an academic accommodation?
Are you requesting an academic accommodation?
Yes
Are you requesting an academic accommodation?
No
How does your disability affect you academically?
How does your disability affect student life in general?
Did you receive accommodations in high school?
(ex: IEP, 504, etc.)
Did you receive accommodations in high school?
Yes
Did you receive accommodations in high school?
No
What type of accommodations have you used?
Are you requesting a housing accommodation?
Are you requesting a housing accommodation?
Yes
Are you requesting a housing accommodation?
No
I request the following accommodations for housing
[select]
Single Room
Air Conditioning
Emotional Support Animal
Room near restroom
Room with private bath
Gender Neutral Housing
Exemption from Campus Housing
Other (Please explain below)
clear
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Other Housing Accommodation
Please Explain
How does your disability affect your ability to enjoy standard Hanover College housing (double room without AC)?
Please state how your housing accommodation request will assist with or ameliorate symptoms of your stated disability.
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