Page 1 of 1

Disability Accommodation Request

Complete this form in full to submit your disability accommodation request.
Once all required information has been received, reviewed and assessed by Disability Services, a decision will be made and provided, in writing, within 30 business days.

Name

Phone

Email

Address

Please describe and provide a history of your disability:

Please explain how your disability impacts your ability to participate in Meridian’s admissions process (if you are an applicant) and/or academic programs (if you are or will be an enrolled student):

Does your disability impact activities outside of the activities for which the current accommodations are being requested? If your answer to the foregoing question is “Yes” please describe:

Do you take any medications for your disability? If your answer to the foregoing question is “Yes” please describe:

Do you currently use any auxiliary aids, special equipment or assistive technology to assist you with any daily activities of living? If your answer to the foregoing question is “Yes” please describe:

Are you currently under the care of any healthcare or other service provider(s) for your disability? If your answer to the foregoing question is “Yes” please list all such provider(s), including their contact data, and describe the nature of the services they are providing to you to treat the disability for which you are now seek an accommodation:

Have you ever been provided a reasonable accommodation by another educational institution? If your answer to the foregoing question is “Yes” please describe:

Please describe the type of accommodation(s) you require and explain how it relates to and supports your claimed disability

Is your accommodations request temporary or permanent?

All requests for disability accommodations must be supported by appropriate documentation furnished by a qualified professional. Requests for a disability accommodation cannot be properly and fully considered by Meridian until appropriate supporting documentation is provided to Disability Services. Please provide documentation prepared by your treating provider(s) that contains a diagnosis of and/or otherwise supports the existence of your claimed disability, including, if available, any accommodation recommendations made by such provider(s).

Authorization - Acknowledgement

In order to process your request for a disability accommodation, it may be necessary for Meridian to share, review and communicate with others about information that is subject to and protected by the Family Educational Rights and Privacy Act (“FERPA”); however, Meridian will only do so on a need-to-know basis, i.e., as needed to determine your eligibility for a disability accommodation and to provide you with same if and as indicated by such information. You understand, acknowledge and agree that Meridian may speak with and/or request information concerning your disability (“Disability Information”) from your treating provider(s), who shall, upon being furnished a copy of this form, be permitted to share with and provide to Meridian any such Disability Information, including and related supporting documentation, that may be required or requested by Meridian to assess your request for a disability accommodation. You further understand, acknowledge and agree that this permission granted by you is voluntary and that Meridian cannot consider your request for a disability accommodation without receiving and assessing such Disability Information. You expressly grant Meridian permission to contact any treating provider(s) that have been identified by you in your Disability Accommodations Request Form, so that Meridian may determine your need and eligibility for any disability accommodation that has been requested by you.

ACKNOWLEDGED & AGREED TO BY

Email

Today's date

Signature

Signature

By clicking submit you agree to the terms and conditions of the above stated Authorization