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Office of Disability Services
Smith College
College Hall 3
Northampton, Massachusetts, 01063
(413) 585-2071 (Voice)
(413) 585-2072 (TTY/TDD)
                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