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Student Request for Reasonable 
Accommodations/Modifications
Intake Application
 
Date_____/_____/_____
 
Personal Information
 
Student’s Name: _______________________________________
 
Local Address_______________________ Home Address _______________________ 
                       _______________________                          _______________________ 
 
Local Phone   _______________________ Home Phone     _______________________
 
Date of Birth ___/___/___ Gender ____Female ____Male 
 
Disability Related Information  (THIS SECTION MUST BE COMPLETED FULLY)
Disability Category (please check all that apply):
         Specific Learning Disability                            ADD/ADHD
         Mobility                                                         Seizure
         Visual                                                            Auditory
         Psychological                                                 Chronic Illness
         Neurological                                                  Physical
 
Specific Diagnosis:______________________________________________________
 
Specific Accommodations Requested (Accommodation Request MUST be included): ____
___________________________________________________________________________
 
Type of Documentation Submitted: _____________________________________________
 
Academic Information
 
Are you admitted to Malone? ____Yes ____No
 
Academic Status:
 
         Incoming Student (Anticipated                       Junior
Date of enrollment) ____/____/____                         Senior
         Freshman                                                                  Graduate
         Sophomore                                                               MCMP
 
Academic Major________________________          Minor: ___________________
 
 
 
Vocation Rehabilitation Information: 
 
Do you receive services from Vocational Rehabilitation or some other office of rehabilitation services?  ____Yes ____No
 
If yes, please provide us with the name, address, and phone number of your VR counselor.
________________________________________________________________________
 
If no, would you like assistance contacting VR for possible funding of services?
___Yes ___No
 
Verification Information
 
I give permission to the staff of the Student Access Center to contact my parents and/or legal guardian and my diagnosing healthcare professional in their attempt to verify my eligibility for academic accommodations.  I understand that this permission extends to the verification process only. 
 
 
____________________________________________        __________________
(Student’s Signature)                                                              (Date)
 
Disclosure Information
 
By completing and signing this intake application, you are voluntarily disclosing a disorder and requesting accommodations.  You understand that disclosure of your disorder at this time does not necessarily confirm your eligibility status for services or accommodations.  You also understand that the verification process may take several weeks or longer, depending upon the appropriateness and currency of the documentation you have submitted.
 
In addition, you understand that all information submitted to this office is to be completely confidential and used only in connection with this institution’s commitment and obligation to students with disabilities unless you have signed a Release of Information form.  The documentation you submit will only be used by this office and by the Office of Equal Opportunity. 
 
By signing below, you confirm that you have read (or have had read to you) and understand this document. 
 
 
____________________________________________        __________________
(Student’s Signature)                                                             (Date)
 
____________________________________________        __________________
(Student Access Center Staff Member’s Signature)              Date)
 
 
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