Public Accommodation Request

Welcome and Thank You!

Thank you for connecting with UCCS Disability Services. Please complete the fields below with information about your education pursuits at UCCS, the impact of your disability and any requested accommodations. Medical documentation is required to support your request, please attach below or email to dservice@uccs.edu. Once submitted, you will receive an email from dservice@uccs.edu with next steps. We look forward to meeting with you!

First Name

Last Name

Middle Name

Student ID

List birthdate "MM/DD/YYYY" if you are not a student or are a new admitted student without access to your Student ID.

UCCS Email

Please use your university issued email address (@uccs.edu)

Student Phone Number

Text Message Reminders

Would you like to opt-in to text message reminders for appointments with UCCS Disability Services?

Date of Birth

Academic History

For which semester are you requesting accommodations?

Are you a...

Disability and Current Impact

Primary Disability

Secondary Disability

Describe how your disability impacts academics and other activities

Is this a temporary medical condition or injury?

Are you requesting Academic Accommodations?

Are you requesting Housing and/or Residential Accommodations

Are you requesting accommodations due to a pregnancy-related condition?

Documentation

For more information on the required documentation for UCCS Disability Services, visit our Documentation Guidelines page on our website.

Please attach a copy of the documentation to this form

Documentation examples include IEP, 504, psychological testing, doctor's letter Acceptable formats include: .docx, .pdf.

Informed Consent for Information Release

I hereby authorize Disability Services at the University of Colorado Colorado Springs to discuss, either in writing or orally, my academic accommodations with appropriate administrators, instructors, professors, and third-party service providers as deemed necessary by UCCS Disability Services staff for the purpose of providing and/or coordinating accommodations and services for me.

Other party (Parent, Spouse, Tutor, DVR Counselor)

Meeting Preference

Student Signature