Public Accommodation Request

Your diagnosed disability/medical condition

How does your disability affect you academically?

How does your disability affect student life in general, like taking tests and studying?

Animal Type

Animal Name

Animal description/color

Animal weight

Animal age

Animal height

Animal history

Date of last vaccination

Location of the vaccination records, in case of emergency?

If applicable, what type of flea and tick treatment does the animal receive?

What training has the animal completed?

Has the animal ever harmed or shown aggressive behavior towards people? If yes, please explain

Is the animal poisonous, venomous or otherwise considered potentially dangerous? If yes, please explain.

Describe the type of assistance the animal provides in relation to your disability.

Please explain the disability-related function that the animal performs for you.

What campus residence are you/or will you be residing at?

Do you have a roommate or suitemates residing with you?

Alternate Off-Campus Caregiver for Animal if Owner is Unavailable

Off-Campus Caregiver Name

Off-Campus Caregiver Relation to Owner

Off-Campus Caregiver Phone Number

Off-Campus Caregiver Address

Off-Campus Caregiver Email Address

Provider Form

The Support Animal Provider Form must be completed by a Licensed Mental Health Practitioner and submitted as documentation via Accommodate, or returned to ADS via email, mail, fax, or hand-delivery.

Have you used accommodations, including resources and services in the past?

If yes, please give as much information as possible. Please include detailed information about accommodations used on any standardized tests e.g. SAT/ ACT/GRE etc.

Accommodations / Resources / Services requested

By submitting this form, I acknowledge that (1) only I, the student or applicant, have filled out this form; (2) this application will not be processed until pertinent documentation of disability has also been provided; (3) Accessibility and Disability Services will consider the accommodations as requested on this form; (4) I authorize Accessibility and Disability Services and individuals providing information in my disability-related documentation to consult as part of the review process; (5) accommodations, if rendered, may not be the same as those received in high school or at another institution, and will not apply retroactively; (6) the accommodation determination process will take up to 14 days; (7) I, the student or applicant, have read and agreed to the Student Rights and Responsibilities.

Accessibility and Disability Services Rights and Responsibilities

Student Rights and Responsibilities

ADS Documentation Guidelines and Registration Process

Coastal Carolina University, through Accessibility and Disability Services (ADS), provides services to students with diagnosed medical/physical disabilities in accordance with the Americans with Disabilities Act (ADA) of 1990, ADA Amendments Act 2008, and Section 504 of the Rehabilitation Act of 1973. To determine eligibility for services, this office requests current and comprehensive documentation of the disability or medical condition from the diagnosing physician or other appropriate professional.

This registration process is intended for use by incoming or current Coastal Carolina University students with a diagnosed disability. ADS recommends students submit the documentation discussed within these guidelines/process at least 14 calendar days prior to the start of the course or exam for which the student seeks accommodations. Please note that accommodations cannot be applied retroactively. Contact Accessibility and Disability Services with any questions regarding the following process:

1. Complete the Accessibility and Disability Services Self-Identification Form. By submission of this form you are also agreeing that you have read and understand the Rights and Responsibilities.

2. Submit documentation from a medical provider, or other qualified professional, regarding your disability or medical condition. The following information must be documented on the provider’s letterhead and must include the following:

a. Diagnostic statement identifying the condition or disability.

b. Date of the most current contact and date of the original diagnosis.

c. Description of the diagnostic tests, methods and/or criteria used to diagnose the condition or disability.

d. Description of the current symptoms and the substantial functional impact of the condition or disability on a major life activity (i.e. how does this condition affect the student’s learning, mobility, communicating, thinking, etc.).

e. Treatments, medications, and/or assistive devices/services currently prescribed or in use, as well as any significant side effects of treatments or medications.

f. Description of the expected progression or stability of the impact of the condition or disability over time, particularly, the next 5 years.

g. Whether the condition or disability described is permanent, long-term (6-12 months), or short-term/temporary (6 months or less).

h. Recommendations for accommodations, (e.g. extended time for exams, preferred seating, etc.).

i. Name of provider/assessor, credentials/title and signature

3. Gather historical disability documentation, such as an Individual Education Plan (IEP), 504 Plan or accommodation letters from prior institutions of higher education.

4. Submit all of the above to Accessibility and Disability Services via encrypted email, mail, fax or in-person. Symplicity Note – ADS is hopeful that all of this information will be submitted via Symplicity when the student registers.

5. Contact Accessibility and Disability Services to schedule an initial accommodation set-up appointment.

Upload supporting document(s)

If documentation is not easily accessible, please complete this registration form and submit documentation at a later date. Documentation can be mailed, emailed, faxed, and hand-delivered to ADS. Please visit the ADS website for contact information. (Ex. IEP, 504 Plan, Psychoeducational Evaluation, Medical Diagnosis)

Public Accommodation Request

Student Information

Specific Accommodation Information

Document Information