Student Accommodations Request - Eastside Catholic School

Studentrequired

First Name

Last Name

Student date of birthrequired

Must contain a date in M/D/YYYY format

Graduating yearrequired

Parent/Guardian or student filling out applicationrequired

First Name

Last Name

Relationship to studentrequired

Preferred emailrequired

Preferred phonerequired

Must contain only numbers

Student IDrequired

Diagnosis information

Is the student's diagnosisrequired

Temporary

Permanent

Please provide documentation of the student's diagnosis; neuropsychologist report, IEP, 504 plan or doctor's letter stating the diagnosis.required

Attach up to 5 files with a maximum size of 20MB

No file chosen

If you selected "Other" above, please specify what type of diagnosis your student has.

Must contain only letters and spaces

Please describe what you understand about your diagnosis or your student's diagnosisrequired

Describe in detail how your diagnosis affects you, or your student, academically and in daily life. Give examples of limitations experiencedrequired

Describe the accommodations you are requesting and how they will alleviate your symptomsrequired

History of Accommodations

Have you used accommodations before?required

Yes

Month, date accommodations startedrequired

Month, date accommodations endedrequired

Month, date accommodations started (if needed)

Month, date accommodations ended (if needed)

Month, date accommodations started (if needed)

Month, date accommodations ended (if needed)

What types of accommodations have you received in the past and how significant were these accommodations in increasing academic success? required

RELEASE AUTHORIZATIONS

EC Learning Support staff engages in an interactive and collaborative process with students and their families in order to determine eligibility for reasonable accommodations. Part of the process includes the submission and review of documentation related to the reported disability or limitations. At times, additional information may be requested. Documentation provided to the Learning Support staff is confidential and only shared with other offices or personnel at EC as necessary to put accommodations into effect. The identification of your disability is kept confidential, unless accommodations are approved and activated and then we will share the information with your teachers and counselors to best serve the student. Disability information may be released upon the student and guardian signing the Student Accommodation Plan.

I understand that any authorizations I make here may be withdrawn by student and guardian at any time through a written, signed and dated request.

Parent/Guardian signaturerequired

I understand that clicking this box is the same as a written signature.

Daterequired

Must contain a date in M/D/YYYY format