Syracuse University Disability Resources Registration Form

* indicates a required field

Student Information

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First NameRequired *

Middle Name

Last NameRequired *

Preferred NameRequired *

Personal Pronouns

SUID#Required *

Use only the first 9 digits of your SUID. (Do not enter any dashes or spaces)

Your SUMail addressRequired *

Please enter your SUMail address (ex. Otto@syr.edu)

Mobile NumberRequired *

Opt Into Text Message AlertsRequired *

Opt Into Text Message Alerts Yes Opt Into Text Message Alerts No

Mobile Carrier

At this time, text messaging can only be enabled for these mobile carriers.

Is this accommodation request for aRequired *

If you have a permanent disability that you will need academic and housing accommodations for, please select "Disability" - you will be given the opportunity to request housing accommodations within the form.

Is this accommodation request for a Disability
Is this accommodation request for a Temporary Disability (ie. broken limbs, concussion, etc)
Is this accommodation request for a Disability Related Housing Accommodation(s) Only - (please contact Renee McNamara at Rlmcnama@esf.edu directly for SUNY ESF housing only requests)

Identify the semester for which you are seeking accommodationsRequired *

I am or will be attending as a(n):Required *

I am also:

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What is the nature of your disability/injury?Required *

When did the injury/disability occur?Required *

How long will you be limited due to your injury/disability?Required *

Condition:Required *

ADD/ADHD Autism Spectrum Blind Deaf Hard of Hearing Learning Disability Low Vision Other (see below)

Do you have a mental health condition?

Do you have a mental health condition? Yes Do you have a mental health condition? No

Do you have a medical health/related condition?

Do you have a medical health/related condition? Yes Do you have a medical health/related condition? No

Describe your condition and how it impacts you on a day-to-day basis. Describe what happens, when, where, and how often. Required *

How is the condition currently impacting you?Required *

How are you currently managing the condition? (ex., therapy, medication, diet & exercise)Required *

Describe in detail where you anticipate experiencing the greatest challenges or barriers living in campus housing.Required *

Specify:

What accommodations/services are you requesting?Required *

Describe in as much detail as possible where you experience the greatest challenges or barriers impacting your ability to learn and demonstrate knowledge.Required *

What accommodations/auxiliary aids have you used in the past and how have they helped?

Describe your learning strengths

Reading Impact and Strategies

Writing Impact and Strategies

Math Impact and Strategies

Classroom Note Taking Impact and Strategies

Time Management/Organization Impact and Strategies

Study Skills Impact and Strategies

Residential Living

What accommodation(s) are you requesting?

Accommodations

Testing Classroom Course Materials in Alternate Format Housing Auxiliary Aids/Technology Other (Please Specify)

If "housing" please specify:

If "other" please specify:

Specific Housing Request(s):Required *

In connection to your condition, what is your rationale for this request?Required *

Disability Affirmation

The Fair Housing Act defines a person with a disability to include (1) individuals with a physical or mental impairment that substantially limits one or more major life activities; (2) individuals who are regarded as having such an impairment; and (3) individuals with a record of such an impairment. Disabilities include, but are not limited to: Mental/emotional disabilities, developmental disabilities, cancer, auto-immune deficiencies such as HIV, autism, cerebral palsy, multiple sclerosis, heart disease, diabetes, asthma, paraplegia, major depression, recovery from an addiction, and many long-term medical conditions.

I affirm that my impairment(s) meets the definition of a disability as described above.Required *

Yes

Disclaimer:

All housing requests fall under the Fair Housing Act (FHA) along with the Americans with Disabilities Act Amendments Act (ADAAA) and Section 504 of the Rehabilitation Act. The approval or denial of requests depends on the circumstances presented and determined on a case-by-case basis. The presence of a disability, in and of itself, does not automatically qualify the student for the requested accommodation(s). All criteria listed on the Housing Healthcare Provider/Advocate Form are necessary for review. All disability-related information is housed within CDR files and kept confidential.

Additional Information Regarding Emotional Support Animal (ESA) Requests:

An ESA must be appropriate for a residential environment. Animals should not be brought to campus prior to approval through the Center for Disability Resources. For more information, refer to the “Assistance Animal Policy” located on the CDR website, disabilityresources.syr.edu.

Meal Plan

A university meal plan is required for those student living in our residence halls. University Food Services employs a full-time registered dietitian who works one-on-one with students on medically prescribed diets. If, after meeting with the dietitian, a determination is made that a disability-related accommodation is necessary, a referral to ODS will be made at that time. **For more information on how to arrange a meeting with the dietitian, please visit foodservices.syr.edu.

I have read and understand the above information.Required *

Yes

Provider/Advocate Information

By typing in the Provider/Advocate information below I authorize Syracuse University to receive information from them. I also authorize my provider/advocate to discuss my condition(s) with the appropriate University personnel to make a proper determination of necessary accommodations. This also indicates that the statements and documentation have been provided by me. I understand that providing false information places me in violation of the Syracuse University Student Code of Conduct and subjects me to any applicable sanctions.

Provider/Advocate Name

Provider/Advocate Contact Information

Expedited Accommodation OptionRequired *

If you are interested in being considered for an expedited review, mark yes, and please complete each field of the registration form and upload supporting documentation. (IEP, 504 Plan, etc.) Marking yes does not guarantee this abbreviated review, as some accommodations may not transfer to the college setting and require a more thorough review. *Students who choose yes, give CDR permission to share your accommodation letter with your instructors.

Expedited Accommodation Option Yes Expedited Accommodation Option No

Upload supporting document(s)

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Syracuse University Disability Resources Registration Form

Student Information

Document Information