Accessibility Services & Accommodations Intake Form

Accessibility Services & Accommodations

Name(Required)

First Middle Last

Academic Major(Required)

Email(Required)

MyBenedict official student email address is required for Special Student Services to email contact students.

Phone(Required)

Please list the requested Accommodation(s)(Required)

Is current medical documentation provided to support the request?(Required)

Please check off college employees you are granting permission to receive written notification of your approved accommodation(s). Please check all that apply.(Required)

Course Professors

College Nurse

College Counselor

Signature(Required)

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Accessibility Services & Accommodations Intake Form

Accessibility Services & Accommodations

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