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.

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 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 on a need-to-know basis? Yes, I agree. The Disability Services Coordinator may share relevant information with the Director of Dining Services 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.