Office of Student Affairs

Accessibility & Accommodation Disclosure and Request Form


The form should be completed when a student is requesting either academic accommodations, and/or special housing arrangements.  Accommodations are based on documented needs from a medical professional.

Student Name
Phone/Email
Disclosure of Disability
Medical Information & Diagnosis: *
Accommodation(s) Requested
Amherst College students with a qualifying disability are entitled to receive reasonable accommodations. Such accommodations are available after: 1) review of submitted documentation from a medical professional, 2) review of the student's Disability Disclosure-Medical Form, 3) on-going conversations between the student and the Coordinator of Accessibility Services. Each accommodation is determined on an individual basis, as supported by the medical documentation.
Please select the accommodations you are requesting based on your documented medical need: *
Academic Work & Classroom Setting
Residential Life & Campus Living
Dietary Requirements & Restrictions
Contact Information for Health Care Providers
Consent to Health Care Providers to Release Information to Amherst College
I hereby authorize the above listed health care providers to release to Amherst College all medical records concerning the disability disclosure herein. I certify that I have read, reviewed and been informed of the academic requirements as outlined by Amherst College and further certify that the foregoing statements are complete, accurate, and true to the best of my knowledge. I also understand the college may require me to undergo further testing for the purpose of establishing existence, or extent of my disability, illness, condition, and thus my need for reasonable accommodations.
Your penned signature, or electronic signature (by typing of your name) provides permission until otherwise revoked in writing by you.
Documentation
IMPORTANT: Please attach appropriate documentation which supports your request for accommodations if applicable.
Please sign and make copies of this form to present to your health care providers so that they may release your medical records to the College.
Please mail or fax or email any associated documentation to: Amherst College Accessibility Services Converse 201 P.O. Box 5000 Amherst, MA 01002-5000-- Fax: (413) 542-8488-- Email: jfoley@amherst.edu