Office of Disability Services
Northampton, Massachusetts, 01063
Disability Identification Form
Smith College is committed to embracing diversity in the college community
and to the individual rights of each member of that community. In accordance
with the provisions of Section 504 of the Rehabilitation Act of 1973 and
the Americans with Disabilities Act of 1990 (ADA), Smith College seeks
to provide students with disabilities those support services and other
reasonable and effective accommodations needed to ensure equal access to
programs and activities of the college.
To ensure
the provision of appropriate accommodations, students must provide current
documentation of their disability by an appropriate licensed professional.
This documentation must indicate a specific diagnosis, information regarding
onset, longevity and severity of symptoms, and must state how the disability
and/or related medications and treatments interfere or limit functioning
in any major life activity, including current participation in courses,
programs, services, or any other activity of the college. Disabilities
may include, but are not limited to, sensory, mobility, psychological or
medical conditions, or learning disabilities and attentiona deficit disorder
(ADD).
The cost of
obtaining documentation is the responsibility of the student. If the documentation
is incomplete or inadequate to support an accommodation request, additional
documentation may be required. Disability documentation
requirements, including psychoeducational testing guidelines for documenting
a specific learning disability or ADD, are available from the Office of
Disability Services. Please contact the Office of Disability Services well
in advance of arriving on campus to arrange any disability accommodations
or services needed. Insufficient notice may result in delays in the provisions
of accommodations or services.
Name
Class
Address
Telephone (
)
Fax ( )
E-mail address
1. Nature of disability:
2. Academic accommodations needed:
3. Special housing accommodations needed:
4. Documentation from a licensed professional is
_enclosed _being sent under separate cover to above
address
Physician or diagnostician
Address
Telephone (
)
Fax ( )
I hereby authorize the Office of Disability Services at
Smith College to receive documentation of my disability. I understand that
this information is confidential and will be used only for the purpose
of enabling Smith College to provide me with supportive, academic, and
other services related to my disability. I understand that the Office of
Disability Services may contact the person providing the documentation
for further information.
Signature of student
Date
Signature of parent or guardian (if student is under
18 years of age)
Date