Public Accommodation Request

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Student Information

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If you are not currently enrolled at Wheaton College, please contact Accessibility Services at accessibility@wheatoncollege.edu

First NameRequired *

Last NameRequired *

Middle Name

Student IDRequired *

EmailRequired *

Please use your university issued email address

Phone NumberRequired *

Class YearRequired *

Are you enrolled in the Pre-College Program?Required *

Are you enrolled in the Pre-College Program? Yes Are you enrolled in the Pre-College Program? No

Is this a request for academic accommodations?Required *

Is this a request for academic accommodations? Yes Is this a request for academic accommodations? No

In as much detail as possible, please describe your diagnosis and how it impacts you as a student in your educational settingRequired *

What types of accommodations have been helpful to you in the past?Required *

What types of accommodations and services are you requesting at Wheaton?Required *

Is this a request for housing accommodations?Required *

Is this a request for housing accommodations? Yes Is this a request for housing accommodations? No

Accommodation(s) requested for: Required *

Current housing assignment:Required *

Building and Room Number:Required *

Is this request related to a temporary injury or impairment?Required *

Is this request related to a temporary injury or impairment? Yes Is this request related to a temporary injury or impairment? No

Please indicate your diagnosed disabilityRequired *

In as much detail as possible, please describe how your diagnosis impacts you as a student in your residential setting

Description of AccommodationRequired *

Please provide a complete description of the desired accommodation and discuss why this accommodation is necessary

Do you require physical modifications within the room?Required *

Do you require physical modifications within the room? Yes Do you require physical modifications within the room? No

If yes, please explain: Required *

Do you require physical modifications in the bathroom?Required *

Do you require physical modifications in the bathroom? Yes Do you require physical modifications in the bathroom? No

If yes, explain Required *

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