Disability Form

Disability Support Services
Lang Wellness Center
Disability Support Services

Disability Support Services, located within Lang Wellness Center, facilitates an accessible educational experience for students who have disabilities and serves as a resource to all members of the campus community. At Rockford University, we are committed to providing an equitable academic and residential environment that supports student achievement. Differences in ability are valued as an integral component of a diverse community. Disability Support Services at Rockford University use the definitions of disability as stated in Section 504 of the Rehabilitation Act of 1973, the Americans with Disabilities Act (ADA) of 1990, and the ADA Amendments Act of 2008.

The steps you need to take to pursue accommodations are outlined below:
1. Complete the Disability Support Services Application and return it to Lang Wellness Center. Application to follow this form.
2. Provide documentation to support the request for accommodations (must be less than 3 years old).
  - Documentation must include a diagnosis by a licensed/certified professional qualified to make such a diagnosis (e.g., school or clinical psychologist, physician, etc.).
  - A school plan such as an Individualized Education Plan (IEP) or a 504 Plan may not be sufficient documentation but may be part of a more comprehensive assessment.
  - If your assessments were completed prior to age 16, ask your high school to conduct/update an assessment prior to graduation or have an independent assessment done by a qualified professional to determine your current diagnosis, treatment, and recommendations for accommodations.
  - If you do not have documentation, please consult with an independent provider for an assessment.
3. Once you have collected your documentation, contact Lang Wellness Center to schedule a meeting with the Disability Support Services Coordinator. During this meeting:
  - The student’s barriers and needs will be discussed and accommodations will be arranged within the guidelines of documentation provided.
  - A release of information will be signed and information regarding your accommodations will be sent to your faculty. You will be asked to meet with each of your faculty to determine the best way to implement your accommodations within the parameters of each class.
  - Students will be required to meet with the Disability Support Services Coordinator at the beginning of each subsequent semester for academic accommodations for that semester.
Please remember to complete your application and provide your documentation to Disability Support Services as soon as possible. This will help to insure your accommodations are in place at the beginning of the semester. For full information, please visit the DSS Handbook: https://www.rockford.edu/wp-content/uploads/2024/09/DSS-Handbook-Rev-September2024.pdf

If you have any further questions, please contact Lang Wellness Center, our phone, email, and fax information is below.

Thank you,
Autumn Schaal, LPC, NCC
Personal Counselor and Disability Support Services Coordinator

Lang Wellness Center

phone 815-226-4083 fax 815-226-3335

HealthCenter@Rockford.edu

Application and Request for Accommodations and Services (to be completed by student)
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.
Rockford University Email*
example@Rockford.edu
Other Email *
example@example.com
Major*
Are you a client of the Division of Vocational Rehabilitation?*

YesNo
If yes, please list your DVR counselor'sname and phone number:*

Disability and Current Impact

In addition to reviewing your documentation, your answers to the following questions will assist us in understanding the current impactof your disability
What is your disability?*
Describe how your disability is currently impacting you in School*
Describe how your disability is currently impacting you at Work*
Describe how your disability is currently impacting you in Social/Personal*
What accommodations are you requesting? (Include academic, physical, and/or communication access needs)*

Academic History
Describe your strengths, weaknesses, and special interests*
What type of high school did you attend?*

PublicPrivate
Name of school*
Are you transferring to RU from another college or university?*

YesNo
Name of college or university transferring from*
Did you have an IEP, 504 Plan or some other school-based support?*

YesNo
What were your grades or GPA in high school or any other undergraduate studies?*
Are you taking any medication or have you participated in any therapeutic services (therapy, coaching, support services, etc.) to manage your condition? If so, please describe whether these were effective or ineffective.*
Approximately how many hours a week do you spend studying/preparing for school?*
Do you feel you will need additional support services (assistance with reading, writing, study skills, time management/ organization,self advocacy skills or informal academic advising, etc.)?*
Documentation to support the request for accommodations is required. If you have an IEP, 504 Plan or a letter from a provider available, please upload documents here. If you do not have documentation accessible at this time, you are welcome to fax, mail, drop off at our office or email (please know that email is not a confidential medium for sharing confidential information). Thank you.

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I hereby authorize Disability Support Services at Rockford University (RU)to discuss, either in writing, electronically or orally, my academic/housing adjustments or accommodations with appropriate administrators, instructors, professors, and third-party service providers as deemed necessary by RU Disability Support Services staff for the purpose of providing and/or coordinating accommodations and services for me.*

Clear
MonthDayYear
Date
Should be Empty:

Disability Support Services

Application and Request for Accommodations and Services (to be completed by student)

Disability and Current Impact

Academic History