Accommodation Request Form

This form is to be filled out by the student requesting disability accommodation; please contact us if you need help filling out this form.
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* = Required Fields
Contact Information
Yes No
Accommodation Request
Yes No

If no, please supply supporting documents from your medical provider that contain the following information (see contact information at the bottom of the form):

  1. Medical professional's name, credentials, and contact information.
  2. Specific diagnosed medical condition(s).
  3. Diagnostic methodology, testing instrument(s), criteria.
  4. Functional limitations caused by these conditions. (How the condition impacts the patient)
  5. Outline of current treatment plan (if applicable).
  6. Stability of condition, expected changes in condition.
  7. Additional Information regarding the condition, functional limitations, or other pertinent information.

It can take up to 15 business days to review your request


Functional limitations caused by your condition. (How does your condition effect you?)

What Accommodation(s) due to these functional limitations do you feel you need?

Tell us your history of accommodation use.

Let us know any additional information you feel we should know.
Campus Resources

Yes No I would like to
Comments:

Yes No I would like to
Comments:

Yes No I would like to
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Yes No I would like to
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Referrer

Gonzaga web site search
Google (or other) search
Word of mouth
Referred by other:
Contact Us

509-313-4134 (voice)

509-313-5523 (fax)

disability@gonzaga.edu

502 E Boone Ave.
AD 19
Spokane, WA 99258-0019