Accommodation Request Form

University of the Potomac does not discriminate in admission or access to its programs on the basis of age, race, color, sex, disability, religion, sexual orientation, or national origin. If a student wishes to request academic adjustment or auxiliary aids, please contact the Disability Coordinator listed below. They may request academic adjustments or auxiliary aids at any time. The Disability Coordinator is responsible for coordinating compliance with Section 504 of the Rehabilitation Act of 1973 and Title III of the Americans with Disabilities Act of 1990. Applicants, who are persons with disabilities, as defined in paragraph 104.3(j) of the regulation under Section 504 of the Rehabilitation Act of 1973, may apply for admittance into the program. The University will work with the applicant or student to determine whether reasonable accommodation is effective and/or available.
If you have a disability and wish to request an accommodation, please complete the form below and return it to:

Disability Coordinator
Student Support Services
1401 H Street, N.W., Suite 100
Washington, D.C. 20005
202-274-2300 / studentservices@potomac.edu

Student ID#*

Student Name*

First NameMiddle NameLast Name

Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please describe the nature of your disability. *

Please describe the documentation you intend to provide.*

Please describe any accommodations you have previously received in an educational environment.*

How does your disability impact your ability to complete coursework or other program requirements?*

List the accommodations requested and rationale for request (use additional paper to complete your responses, if needed)*

Date of onset of impairment (MM/DD/YYYY):

Date

If temporary, expected to last until (MM/DD/YYYY):

Date

All accommodation requests must be supported by appropriate documentation completed by a qualified professional. Accommodation requests cannot be considered until appropriate documentation is received. Documentation attached?*

YESNO

File Upload*

File Type: pdf, jpg, jpeg, png, gif

Signature*

Office Use Only

Disability Coordinator: _________________________________

Date: __________________