Reasonable Accommodation Request Form for Students with Disabilities

Reasonable Accommodation Request Form for Students with Disabilities

Midwest Institute does not discriminate on the basis of disability status in admission or access to its programs and activities. Future students of Midwest Institute must notify the college in advance if special accommodations are needed so that these arrangements can be discussed with the Education Department. Requests for reasonable accommodations are based on mutual planning among the Director of Education, staff, and faculty. The arrangement of reasonable physical and academic accommodations take time and may require follow-up interviews. Please submit your request at the earliest possible date.
Requestor
Date

Month Day Year
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Name

First Name Last Name

Address

Need for accommodation:
Please attach documentation of diagnosed learning disability: (diagnosis must be within the last 36 months)

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Cancel of
Requestor's suggested accommodation:
Suggested accommodation by other agency or individual:
Midwest Institutes accommodation plan:
Request received by:

First Name Last Name
Date

Month Day Year
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Form will be submitted to Mrs. Pandolfo, Director of Education, Midwest Institute

4260 Shoreline Dr, Earth City, MO 63045 Phone: (314) 344-4440 Fax 314-344-0495

You will be contacted regarding accommodation decision within 5-7 business days after submission
For Internal Purposes Only - Do Not Write Below this Line
I concur with the proposed accommodation:
Student Signature
Date

Month Day Year
Date Date Picker Icon
I wish to appeal the committee's proposal:
Date

Month Day Year
Date Date Picker Icon
Accommodation Approved:
Director of Education
Date

Month Day Year
Date Date Picker Icon
Accommodation Approved:
Director
Date

Month Day Year
Date Date Picker Icon
Should be Empty: