Accommodation/Temporary Adjustment Request Form

Please fill out the following form to request accommodations for documented disability-related needs or adjustments for temporary injuries or impairments.

Name Name First Last
Please provide your Waynesburg University email address.
Please select your student status:

Please select your student status: Incoming First-Year Student Returning Student Transfer Student Graduate Student
Please select the appropriate category for your primary disability/diagnosis:

Please select the appropriate category for your primary disability/diagnosis: Learning Disability Autism Spectrum Disorder ADHD Mental Health Disability Physical Disability Chronic Illness Temporary Injury or Impairment Visual Impairment Deaf/Hard of Hearing Other
If you have a secondary disability/diagnosis, please identify it below:

If you have a secondary disability/diagnosis, please identify it below: Learning Disability Autism Spectrum Disorder ADHD Mental Health Disability Physical Disability Chronic Illness Temporary Injury or Impairment Visual Impairment Deaf/Hard of Hearing Other
Please describe how your disability(ies)/diagnosis(es) impact you in academic and/or residential settings:
Please identify your requested accommodations:
Optional: please upload digital copies of documentation to support this request. Documentation may also be submitted to the Disability Services Coordinator in-person or via mail, email, or fax. Important: please note that some types of requests (e.g., requests for housing accommodations or assistance animals) have fairly specific documentation criteria. Please review the "Eligibility Process" tab of the Disability Services website or contact dso@waynesburg.edu to learn more about documentation requirements.

Attach Files

Documentation may also be sent directly to the Disability Services Coordinator at the following address:
Disability Services Office
Email -- dso@waynesburg.edu or sarah.feldberg@waynesburg.edu
Mail -- C/O Sarah Feldberg, Disability Services Coordinator
Waynesburg University
51 West College Street
Waynesburg, PA 15370
Fax -- 412-218-3705
If this is a request for a dining accommodation, do you authorize the Disability Services Coordinator to discuss your dietary needs with the Director of Dining Services and other Aladdin Dining Services staff on a need-to-know basis?

If this is a request for a dining accommodation, do you authorize the Disability Services Coordinator to discuss your dietary needs with the Director of Dining Services and other Aladdin Dining Services staff on a need-to-know basis? Yes, I agree. The Disability Services Coordinator may share relevant information with the Director of Dining Services and other Aladdin Dining Services staff for the purpose of arranging accommodations. No, I do not agree. I am not requesting a dining accommodation, so this question is not relevant to me.