Accommodation Request

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Student Information

Please enter your information

First Name

Last Name

Middle Name

Student ID

Please use your Concordia College issued email, ending with: @cord.edu
If not a currently-admitted student of Concordia College, please input your preferred email address

Phone Number

Student Status

Diagnosis Status

Specific Accommodation Information

Please state diagnosed disability(ies) and the date of onset

Please describe how your disability affects you academically (include functional limitations, such as concentration, comprehension, reading, hearing, etc.)

Please describe how your disability affects life outside the classroom (social, living, sleeping, dining, etc.)

Please list accommodations you have received in the past related to your disability

Please list and describe Accommodation(s)/Services you are requesting

Please list the name(s) of your medical and/or mental health provider(s)

Upload supporting document(s)

Please upload your supporting document(s): IEP, 504 Plan, letter(s) from healthcare provider(s)

Accommodation Request

Student Information

Specific Accommodation Information

Document Information