Request for Access Accommodations

* indicates a required field

Student Information

Please enter your information
*
*
*
ex. C01234567
*
Please use your university issued email address
*
(###) ###-###
Date of Birth
On which campus(es) will you be attending classes?



















Specific Accommodation Information

*
Are you currently being treated for your disability?(Required) *
*
medication, vocational rehab, counseling, equipment, or software
*
Testing, lecture, accessing faculty, reading, writing, computer access
*
For example, family commitments, work commitments, transportation, etc.
*
*
*
*
*
*
Documentation Guidelines

Choose the link below to review Disability Support Services Documentation Guidelines.
https://www.ivytech.edu/dss/

Release of Information

You may authorize the Office of Disability Support Services (DSS) to communicate with the following individuals, agencies, or service providers regarding your access accommodations and services. This release will remain in effect until you rescind the authorization.
Ivy Tech faculty and staff such as Advisor, Financial Aid, Registrar, Test Center, etc.(Required) *
External Constituents such as diagnosing or treating physician or school that previously provided services(Required) *
Source of Documentation such as treating or diagnosing physician or school that previously provided services(Required) *
Name, relationship, phone number