Student Initial Request for Accommodation

Directions: Please complete and submit the following information. The Peru State College Disability Services Coordinator will contact you to discuss your request.
Date of Request Date of Request * / MM / DD YYYY
Legal Name Legal Name * First Last
Phone Number Phone Number * - ### - ### ####
Email: (Please use your campus e-mail if a current student) *
I have used Post-Secondary Accommodations Previously *

I have used Post-Secondary Accommodations Previously Yes (If Yes, see below) No
Please list Where you have previously used Post-Secondary Accommodations:
Written Documentation of My Disability is Currently Available and Can Be Provided Upon Request *

Written Documentation of My Disability is Currently Available and Can Be Provided Upon Request Yes No
Draw your signature into the box below. *

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.