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    Accommodations Request Form

    Complete this form with the information specific to a diagnosed disability for which you are requesting academic accommodations. It will be reviewed upon receipt of the form and you will be contacted about the specific information that is needed from your medical provider.  If you have any questions in the meantime, please feel free to contact us at GSON-Accommodations@barnesjewishcollege.edu.
    Birthdate
    Birthdate
    Start term of your request
    Start term of your request
    Program/Degree Level
    Program/Degree Level
    Requesting academic accommodations for the following diagnosed disabilities (check all that apply)
    Requesting academic accommodations for the following diagnosed disabilities (check all that apply)
    Have you previously received accommodations?
    Have you previously received accommodations?
    I understand that requests for academic accommodations must be accompanied by current documentation of my diagnosed disability. Barnes Jewish College Goldfarb School of Nursing follows the Missouri State Board of Nursing guidelines. The documentation that I present to Disability Services must meet documentation guidance relevant to my academic coursework. While I can request accommodations, Disability Services has the right to determine appropriate and reasonable accommodations for my situation based on the information presented in the documentation and/or my personal preference. If I am informed that I need additional, up-to-date documentation for a specific accommodation request, I understand I am personally responsible for obtaining this information per general higher education procedures.

    All documentations will be solely used for the purpose of determining both service eligibility and reasonable accommodations to be provided. Information from my documentation and specific reference of my diagnosed disability will not be placed on any official academic records or transcripts.

    I have read the above information and understand the process and my responsibilities in seeking academic accommodations at Barnes Jewish College Goldfarb School of Nursing.
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    Today's date
    Today's date
    I authorize and request that Disability Services release and/or obtain all confidential information required in the course of the evaluations and treatments of my disability. This information is to be solely used for the purpose of providing academic accommodations. Barnes Jewish College Goldfarb School of Nursing only retains documentation for one term. Students should keep their personal records to provide to the Missouri Board of Nursing when seeking accommodations for licensure.
     
    By marking the following boxes, I give Disability Services my permission to speak with the following people on my behalf for the purpose of providing and successfully arranging accommodations and related support services:
    By marking the following boxes, I give Disability Services my permission to speak with the following people on my behalf for the purpose of providing and successfully arranging accommodations and related support services:
    I understand that I may revoke this authorization at any time by informing the Disability Services office and the above parties in writing, except to the extent that prior action has been taken on it. This authorization will expire one year from the signature date below.
    I will need to renew this release after this date to continue receiving accommodation.

    In consideration of this authorization, I hereby release the above parties from any legal liability for the exchange of my information.
    Click to Sign...
    Today's date
    Today's date
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