Additional Navigation Student Access OfficeStudent Access Office Forms Information for Parents Student Access Committee Policies and Procedures Student Access Office Forms Accommodation Request Form Accommodation Request Form Name *Student ID # *Avila Email Address *Alternative Email Address *Permanent Home Address *Campus or Local Address *Phone *Cell Phone *Emergency Contact Name *Emergency Contact Phone # *I am requesting services for (year): *Enter the year you would need servicesTerm *FallSpringSummerI am a *Undergraduate StudentGraduate StudentAdult Undergraduate StudentOtherPlease Specify "Other" *I am a (check one): *first time Student Access Office accommodation recipient.returning Avila student and I have previously submitted the necessary documentation.returning student with previously submitted documentation, but I have additional documentation I would like to have added to my file (attach copies) OR am requesting a change in my accommodations.Upload additional documentation to be added to your file.Choose FileNo file chosenDelete uploaded fileI have (check one): *enrolled for my classes (advise our office immediately if you change your schedule.)not yet enrolled for my classes, but I will enroll on or before (add date below)I understand that it is my responsibility to notify the Student Access Office when I enroll. I also understand that late enrollment may delay the fulfillment of my request.Registration Date for classesIf you have not enrolled yet, when will you enroll?Accommodations Requested *Please be as specific as possible, noting for which courses the requested accommodations are needed):Type Your Name as your Signature *Date *This information contained in this form, and in any attachments, is true and accurate to the best of my knowledge. I agree to allow the release of my name and contact information to note taker(s) assigned to my classes if this is an approved accommodation for the indicated semester. In addition, I agree to allow the release of my name and contact information for the purpose of securing alternative textbook formats if this is an approved accommodation for the indicated semester. Send Message Student Information Form Student Information Form First Name *Middle NameLast Name *Date of Birth *Student ID#Major *Avila Email Address *Alternative Email Address *I am currently receiving information/assistance from:Division of Vocational RehabilitationBureau for the BlindU.S. Department of Veterans AffairsAvila University Financial AidOther (Please Specify)State NameOther (Please Specify)Name of counselor/agency contact:PhoneDate of most recent documentation of disabilityType of Disability *Doctor's NamePhoneEmergency Contact Name *Phone *Date *Type Your Name as your Signature *Date *I hereby authorize release to Avila University information concerning my disability and educational/vocational history for the purposes of providing me with services. I understand that the information obtained by Avila University will be held in the strictest confidence and not be released directly or indirectly without written consent except for the purpose of providing services. The information contained in this form and any attachments are true and accurate to the best of my knowledge. I hereby authorize release to Avila University information concerning my disability and educational/vocational history for the purposes of providing me with accommodation services. I understand that the information obtained by Avila University is confidential and not be released directly or indirectly to parties outside of Avila University without written consent except for the purpose of providing services. Send Message Interpreter Request Form Interpreter Request Form First Name *Last Name *StudentEmployeeGuest/VisitorOtherIf other, please indicate:What Date Will You Need the Interpreter (MM/DD/YYYY)? *Select the Starting Time for the Interpreter (i.e. 8:00 a.m.): *12010203040506070809101100153045AMPMSelect the Ending Time for the Interpreter: *12010203040506070809101100153045AMPMLocation: *Building: *Room: *Request Type *Class RequirementExtracurricular ActivityStudent/Advisor MeetingCall/TeleconferenceExam/QuizPersonnel MeetingTutoringVideo/Recorded PresentationPerformance/PlayOther Meeting or EventIf Other Meeting or Event, Please Specify:Event Contact Person's First Name *Event Contact Person's Last Name *Event Contact Person's Phone Number *Event Contact Person’s Email Address *Please specify how you wish to communicate with the person (e.g., American Sign Language, Transliterating, Oral):Additional Information or Details:All requests must be returned to the Student Access Office (SAO) as far in advance as possible, but at least five (5) business days prior to an event (requests submitted after that time will be filled as interpreters are available). Changes and cancellations of requests should be made at least two (2) business days prior to an event. Failure to notify the SAO of a change or cancellation may result in a delay or inability to provide interpreting services.I acknowledge that before requesting accommodations I have read, understand, and agreed to comply with the policies pertaining to interpreter services of Avila University. I agree to report immediately to the SAO any schedule changes, room changes, or problems that arise.Type Your Name as your Signature *Today's Date * Send Message Grievance Form Grievance Form First Name *Last Name *Apartment, suite, etcCountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaAustraliaArubaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCabo VerdeCayman IslandsCentral African RepublicChadChileChina, People’s Republic ofChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d’IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench South TerritoriesGabonGambiaGeorgiaGermanyGuernseyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard Island And Mcdonald IslandHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJerseyJohnston IslandJordanKazakhstanKenyaKiribatiKorea, Democratic People’s Republic ofKorea, Republic ofKosovoKuwaitKyrgyzstanLao People’s Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauNorth MacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontserratMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunion IslandRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSaint HelenaSaint Pierre & MiquelonSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and South SandwichSpainSri LankaStateless PersonsSudanSudan, SouthSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwan, Republic of ChinaTajikistanTanzaniaThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks And Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUS Minor Outlying IslandsUnited States of America (USA)UruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis And Futuna IslandsWestern SaharaYemenZambiaZimbabweStudent IDPhone *I am filling a grievance involving the following form of discrimination or harassment:Unfavorable treatment of a student because of their disabilityDenial and/or inappropriate implementation of reasonable accommodationsLack of physical access to University facilities and/or programsOtherIf selected Other, please state grievance here:I have the following complaint:Provide date(s) the action occurred: *State how the action(s) is/are discriminatory (or how the decision is unreasonable if it is a denial of a requested accommodation): *The grievance is filed against the following individual(s):The following individuals have information the University should consider in resolving this complaint:I am seeking the following accommodation and/or resolution in conjunction with my complaint:Type Your Name as your Signature *Today's Date * Send Message