EVERGLADES UNIVERSITY
Request for Adjustments/Accommodations

Student Number:  	

Name (Print): 	

Home Address:	

Phone #: 	

Cell or other Phone: ______________________

Email: ______________________________________________________________

Are you a:	Current Undergraduate Student
Current Graduate Student Prospective Undergraduate Student Prospective Graduate Student

Please check the Everglades University campus you are/will be attending:
Boca Raton	Online	Sarasota	Orlando	Tampa

Please indicate your major (if known):

I am requesting adjustments/accommodations from Everglades University because I have been diagnosed with: (check all that apply).
Attention Deficit Disorder
Physical Disability (specify type):_ 	 Learning Disability
Psychological Disability
Other Disability (specify type):  	

Date First Diagnosed:  	___________________________

In the space below and on the back of this sheet, list and explain each of the adjustments/accommodations you are requesting. Please be as specific as possible. For example, if one of your requests is extended time for in- class exams, specify the amount of additional time (e.g., "50% more time on in-class exams").

Student Signature:  	

Date: