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Public Accommodation Request
The SVA student should complete and submit this request. If you need assistance completing this form, please email disabilityresources@sva.edu from your SVA issued e-mail address.
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indicates a required field
Student Information
Please enter your information
First Name
Required
*
Last Name
Required
*
Middle Name
Preferred Name
Required
*
Pronouns (she/her; he/his; they/their; etc.)
Required
*
Please let us know what pronouns we should use to refer to you.
Student ID
Required
*
Email
Required
*
Please use your SVA issued email address
Phone Number
Required
*
Accessibility Specific Information
Instructions: There is much variability within each accessibility category, and therefore, the type of accommodations needed can vary significantly. Below, you will find descriptions of the various types of disabilities recognized in the United States. Student needs vary according to each individual. Therefore, it is important for the participating student to clarify the particular accommodations she or he requests
What is/are your specific disability/disabilities?
Required
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When was your disability first diagnosed?
Required
*
Do you have any documentation of your disability?
Required
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Do you have any documentation of your disability?
Yes
Do you have any documentation of your disability?
No
What type of documentation do you have?
504 Plan
Audiological Report
Comprehensive Medical Report
Diagnostic Evaluation
Doctor's Note
Educational Evaluation
Individualized Education Plan (IEP)
Neurological Evaluation
Neuropsychological Evaluation
Other
Psychoeducational Evaluation
Psychological Evaluation
Vision Report
Are you currently taking any medications related to your disability?
Required
*
Are you currently taking any medications related to your disability?
Yes
Are you currently taking any medications related to your disability?
No
What medications are you taking? Please indicate what side effects, if any, you experience from these medications.
How does your disability affect you academically?
Required
*
How does your disability affect student life in general?
Required
*
What accommodation(s) are you requesting?
Required
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Please type out each accommodation you are requesting.
Is there anything else we should know? Tell us here.
Who referred you to Disability Resources?
Would you like to schedule ongoing (weekly or bi-weekly) appointments with Disability Resources staff?
Required
*
Would you like to schedule ongoing (weekly or bi-weekly) appointments with Disability Resources staff?
Yes
Would you like to schedule ongoing (weekly or bi-weekly) appointments with Disability Resources staff?
No
Semester
Required
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Fall
Spring
Summer
Year
Required
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2024
Upload supporting document(s)
Please upload your documentation here. If you have difficulties, you can also e-mail it to us at disabilityservices@sva.edu or bring it with you to your initial intake appointment.
Document Information
Document Title
Required
*
File
Required
*
Maximum file size: 10240kb
Description