Request for Disability Services Online Form

* = required field

Student's Name*
Email address*
Zip Code*
Phone number*
Cell phone
Please describe your disability, including how long you have been identified and interventions that have been successful in the past.
Discribe your disability.*
Please list the name(s)/title(s) of professionals that will be providing documentation of your disability. Note: information must be provided by appropriately certified/licensed personnel and must be less than three years old. Documentation should be provided using either the Disability Documentation form (on the web page) or in a separate report which addresses all the questions on that form.
Names/titles of professionals*
Please outline accommodations you feel would assist you in having equal access to educational opportunities at Luther College.
Outline accommodations*
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Signature (please type)*
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