Online Student Application

Questions

1. When was your diagnosis first identified or diagnosed?
2. Have you been evaluated/treated for this disability? If so, please indicate the title and credential of the evaluating professional.
3.  

   Have you received accommodations for this disability in the past? * (Selection is Required)

   Yes (Specify Below)

   No

   Additional Note or Comment
4.  

   Are you currently taking any medications that might affect your attendance or performance at Bethel? If so, please describe. * (Selection is Required)

   Yes (Specify Below)

   No

   Additional Note or Comment
5. Please describe how your diagnosis affects you in an academic setting (i.e. listening, note taking, writing, typing, attendance, papers, etc.)
6.  

   Does your diagnosis impact you with time constraints (i.e. timed tests, deadlines, class schedule, etc.)? * (Selection is Required)

   Yes (Specify Below)

   No

   Additional Note or Comment
7.  

   Does your diagnosis affect your mobility (i.e. manipulating objects, transportation, navigating campus, etc.) * (Selection is Required)

   Yes (Specify Below)

   No

   Additional Note or Comment
8. If living on campus, does your diagnosis impact your housing?
9.  

   Does your diagnosis impact you in any other way or area that you would like to share with us? * (Selection is Required)

   Yes (Specify Below)

   No

   Additional Note or Comment

1. I understand that I am registering with the Office of Accessibility Resources and Services at Bethel University and that I may be eligible for services such as information, referral, and reasonable accommodations that may be needed for access to courses, activities, programs, employment or facilities.

2. I understand that, in order to receive reasonable accommodations, I may be required to provide current documentation of my diagnosis and its impact in an academic setting from an appropriate licensed
professional (See Guidelines for Documenting Disabilities). I understand that Bethel University may deny a request for reasonable accommodations if the documentation demonstrates that they are not warranted, or if I fail to provide appropriate documentation. If the initial documentation is incomplete or inadequate to determine the extent of the diagnosis and reasonable accommodations, the Office of Accessibility
Resources and Services has the discretion to require additional documentation. Any cost of obtaining documentation from a titled or credentialed profession is my responsibility.

3. I understand that if I request the Office of Accessibility Resources and Services to facilitate accommodations on my behalf, they may need to consult with other Bethel faculty and/or staff. I authorize my disability related information to be shared with appropriate Bethel personnel (e.g., Human Resources, Financial Planning, Student Life, Dining Services, Academic Enrichment and Support Center, Security and Safety, and/or appropriate faculty members) to facilitate my accommodation requests. Information will be shared on a need to know basis and the information shared will retain its confidential safeguards.

By submitting this application you are initiating your request to be registered as a student with accessibility needs in accordance with state and federal regulations.