Fillable ApplicationforServicesandAccommodations Fillable Applications for Services and Accomodations

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ApplicationforServicesandAccommodations Fillable Applications for Services and Accomodations

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Revised 8/2019
@hawaii.edu
□
Yes
□
No
Date
Primary Phone
Other Phone
UH Email
Name
Relationship
Phone
History
In Case of Emergency
Description of disability and accommodations needed
Date of onset of disability
Name of VR Counselor or MH Case Manager
List of previous academic accommodations provided
City, State
Contact (phone or email)
Disability Services
200 W. Kawili St.
Hilo, HI 96720
Student Services Center (SSC) Room E-230
http://hilo.hawaii.edu/studentaffairs/uds
Phone (808) 932-7623
Fax (808) 932-7768
TTY (808) 932-7002
Email uds@hawaii.edu
Address
City, State
Zip
Please allow at least two weeks (or more during the summer before the first term of entry) for Disability Services (DS) to review
your application and supporting documentation. Please note that your application cannot be reviewed until all documentation
is received. All accommodation requests will be evaluated based on your supporting documentation. Documentation guidelines
are available online. After DS has reviewed your application and documentation, you will be contacted to schedule an
appointment.
Student Information
DOB (MM/DD/YY)
Name
Student ID
Application for Services and Accommodations
Notified Depts.
Signature
Date
Please complete this form, sign, and return to Disability Services at SSC E-230 or mail to the address above.
By signing the Application for Services and Accommodations, I understand that it is my responsibility to notify the DS office in advance of the
request for services and accommodations. Moreover, I affirm that the information contained herein is accurate as of the date indicated below and
I acknowledge my responsibility to provide DS with any necessary updates. I hereby authorize DS to use the information included in this
application in their database and as a guideline in the provision of services and accommodations and acknowledge that said information will be
archived within the DS office until date of termination of services and accommodations.
Svcs. Start Date
□ Other UHH Departments Notified
DS Office Use Only
Expected End Date (TD Only)
Disability Services has my permission to discuss the nature or type of my disability-related needs with the
UHH faculty/staff as needed to provide appropriate services and accommodations.
Confidentiality Statement
Disclaimer and Signature
Address
City, State
Zip
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Completed 21 February 2020

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