Request for Accommodations

* indicates a required field

Student Information

First Name

Last Name

Preferred Name

Preferred Pronouns

Simpson ID

Simpson Email

Transfer Student?

Are you the first generation in your family to attend college?

What type of accommodations are you seeking?

Please check all that apply

If you are requesting housing accommodations, please have your provider complete the below form

Housing Provider Form

If you are requesting an Emotional Support Animal (ESA), please complete the below forms

ESA Provider Form

ESA Student Form

I am disclosing the following disabilities/conditions/diagnosis

Optional

Please indicate how you disability substantially limits one or more major life activities at Simpson

Authorization for Release

I hereby authorize the representatives of Simpson College Student Accessibility Services office and./or Academic Affairs to be permitted to review and obtain copies of information concerning my health, academic, and assessment records for the purpose of evaluating eligibility and accommodation requests.

I further authorize representative of the aforementioned offices to be permitted to release, discuss, and exchange disability and or accommodation request information with Simpson College faculty, staff, or affiliated rehabilitation agencies on a need-to-know basis in order to provide full coordination of services.

I agree that any person(s) who may furnish information concerning my records or test data or therapist/counseling notes shall not be held accountable for releasing this information or any attempt to comply with it.

I further release Simpson College from any and all liability for damages of whatever kind, which may at any time result to me, my heirs and family or associates because of compliance with this authorization, or any attempt to comply with it.

I understand that I may revoke this authorization at any time, except to the extent that action has already been taken in reliance upon it, and by giving written notice to the Student Accessibility Office.

Student Signature

Date

Upload supporting document(s)

Documentation submitted must:

• be on professional letterhead
• Denote absence/presence of disability
• include the impacts of the stated disability on daily activities
• Recommendations of the provider to mitigate or alleviate the stated impact
• Provider signature

See additional documentation guidelines here.

Request for Accommodations

Student Information

Document Information