Online Student Application

Questions

1.  

   Are you requesting an accommodation related to housing or dining? * (Selection is Required)

   No

   Yes. Do not complete this application unless you are also requesting academic accommodations. Please complete a Housing Accommodation Application. See link provided above.

   Additional Note or Comment
2.  

   What is your academic status? Check all that apply.

   Incoming First Year

   First Year

   Second Year

   Third Year

   Fourth Year

   Transfer

   Readmitted

   Additional Note or Comment
3.  

   Are you applying for accommodations for a condition lasting six months or less? If so, please submit a Short Term Medical Form or other documentation. * (Selection is Required)

   No

   Yes. Please submit the Short Term Medical Condition Form.

   Additional Note or Comment
4.  

   The documentation I will submit verifies I have the following ONGOING disability. Please check any that apply.

   My condition is temporary. I will submit a Short Term Medical Condition Form.

   ADHD/ADD

   Autism Spectrum Disorder

   Chronic Health Impairment

   Hearing Impairment

   Learning Disability

   Mobility Impairment

   Neurological Impairment

   Psychological Disability

   Speech/Language Impairment

   Vision Impairment

   Unsure or Other (specify below)

   No Documentation. I am submitting this form to explore the possibility of qualifying for disability services.

   Additional Note or Comment
5. Briefly describe your own understanding of your current impairment and any relevant diagnosis.
6. Describe how your disability(ies) limits your functioning in a learning environment.
7. What academic accommodations are you requesting while at Westmont College?
8.  

   Did you receive accommodation(s) in the past? * (Selection is Required)

   No

   Yes. Please describe past accommodations and when you received them.

   Additional Note or Comment
9. When and by whom were you recently evaluated/treated for the condition(s)?
10.  

    How did you hear about our office? * (Selection is Required)

    Through Admissions.

    Through the website.

    Through a friend.

    Through a course syllabus statement.

    Referred by a professor.

    Referred by Westmont Health or Counseling Center.

    Referred by Westmont Tutoring Center or other Student Success staff member.

    Referred by a Residence Life staff member.

    Other, please specify below.

    Additional Note or Comment
11.  

    Did you complete this application personally? * (Selection is Required)

    Yes, I personally completed this application.

    No, this application was completed on behalf of the student. Please specify by whom and your relationship to the student below.

    Additional Note or Comment
12.  

    By submitting this form, I certify that the information provided on this form is accurate. I understand that to be eligible to access accommodations at Westmont College I must (1) submit this completed form, (2) submit disability documentation that substantiates the requested accommodations, and (3) participate in an initial individual interview with an ODS staff person. * (Selection is Required)

    Yes, I agree with this statement.

    Additional Note or Comment