Registration Form

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Confidential Request for Accommodations

The Office of Accommodations and Disability Access supports students with disabilities to obtain reasonable accommodations in the classroom, online learning environments, and across campus communities. Please complete this form to initiate your request.


Current Students: We recommend starting the process of requesting accommodations for the first time, at least one month before the start of the semester. Students can request accommodations at any time, but a delay in requesting may delay the provision of accommodations.


Returning Students: Students who are returning to campus after a leave of absence or completion of an initial degree program, must contact ada@dom.edu to update accommodations and learn about revised processes.


With respect for time for implementation, no new academic accommodations will be granted with less than one month remaining in a semester. This will be the case as of April 5, 2024. Intakes for subsequent semesters will resume after finals.


Please email ada@dom.edu with any questions.

  
Please use your university issued email address
Please check all that apply to youRequired

Diagnostic History

Which of the following diagnostic categories best describe you? Please check all that apply.Required

Accommodation History

Have you previously recevied accommodations in high school or at another university?

Academic Accommodation Request

I am requesting academic accommodationsRequired

Housing Accommodation Request

I am requesting housing and/or emotional support animal accommodations.Required
Are you requesting an ESA (Emotional Support Animal)?Required

Meal Plan Accommodation Request

I am requesting meal plan accommodations.Required

Additional Information

Do you have any additional information to provide?Required

Campus Emergency Evacuation Accommodations

Do you require assistance in the case of an emergency on campus to evacuate?Required

Documentation

Documentation Upload

ADA requires documentation of your disability.  Once the appropriate documentation is received, an appointment should be scheduled with an ADA staff member to review and determine reasonable accommodations. 


If you have questions about documentation guidelines please visit dom.edu/ADA or contact ADA at ada@dom.edu.

Service Agreement and Release of Information

By submitting this request for accommodations, I agree to participate in the interactive intake process to have my accessibility needs assessed.

I understand that accommodations are not retroactive, and it is my responsibility to do the following:


• Submit all necessary documentation of a medical condition and/or disability to the Accommodations and Disability Access office


• Attend an intake meeting with Accommodations and Disability Access staff to discuss my needs and establish reasonable accommodations


• Initiate accommodations with faculty or housing staff in accordance with established procedures, in a timely manner


• Consult with the Accommodations and Disability Access office if I am unclear about procedures or if I am informed by faculty or housing staff that a particular accommodation cannot be met


• Comply with the University Student Code of Conduct


Furthermore, I understand that personnel in the ADA office may need to communicate with other personnel at Dominican University in order to provide accommodations for disability. This authorization is for internal Dominican University purposes and it does not include permission to release information to a third party. 


This consent is valid during the entirety of my enrollment at Dominican University. I understand that I may revoke this consent at any time by submitting to the ADA office a written revocation that is signed by me and witnessed by another person who knows me. 


I authorize personnel in the ADA office to release information about my accommodations for the purpose of coordi‐ nating accommodations for my disability to the following:


- Academic Advisor
- Program Director
- Clinical Coordinator
- Academic Dean
- Department Chair
- Faculty/ Instructor
- Division of Student Success and Engagement
- Division of Athletics
- Financial Aid
- Tutoring and Academic Coaching
- Any Dominican University personnel as ADA staff deem necessary

Do you consent to the previously provided text?Required

I understand that by typing my name, ID number, or any other response below, I am indicating that I agree to the terms outlined above.