Pitzer College, Office of Study Abroad, West Hall, Suite 100, 1050 North Mills Avenue, Claremont, CA 91711
Telephone 909.621.8104 Email firstname.lastname@example.org
Pitzer College Request for Accommodation
This form must be completed by all participants and is due by the deadline indicated in their acceptance letter.
Pitzer College does not discriminate on the basis of disability in the administration of its admission policies, educational
policies, or other College-administered programs. In many of the countries in which we approve or operate study abroad
programs, however, possibilities for reasonably accommodating students with certain physical, medical, psychological
or learning disabilities may be limited. The ability of Pitzer College, the exchange host institution or the program sponsor
to offer reasonable accommodations during an exchange will vary from program to program and is addressed on a case
by case basis.
If you have a physical, medical, psychological, or learning disability, or there are any other factors for which you may
require reasonable accommodation or the ongoing care of a physician or therapist, it is essential that you clearly state
this information on the form below. We will discuss your case with you, request additional documentation or information
if necessary, and make an assessment of what reasonable accommodations or arrangement for ongoing care can be
made to meet your needs while on exchange. You can then make an informed decision about the viability of your
participation on a specific program. The information provided by students on this form will be maintained separately
from applications to participate in an exchange program and will not be considered in admissions decisions for the
programs. Please check one of the boxes below:
□ I do not have any physical, medical, psychological condition, learning disability or any other situation for which I will
require reasonable accommodation in my program or ongoing care of a physician or therapist. Should this change
prior to participation, I understand I must notify the Office of Study Abroad and International Programs immediately
to determine what reasonable accommodations can be provided. Skip questions 1, 2 and 3 and complete the
information at the bottom of this page.
□ I have a physical, medical, psychological condition, learning disability or other situation for which I will or may
require reasonable accommodations or the ongoing care of a physician or therapist while participating on my
exchange program. If you check this box, please answer questions 1, 2 and 3 and complete the information at the
bottom of this page.
1. What accommodation are you requesting? Be specific. Please describe in detail the nature of your disability or
special need. Continue on the back of this form if you need more space to write.
2. How do you anticipate your disability or special needs will impact your participation on the program?
3. What accommodations are currently provided by your home institution to meet your special needs? (Please note
that Pitzer College may not be able to provide a similar level of reasonable accommodation while you are on
I give permission to the Office of Academic Support, the Dean of Students or other appropriate officials at my home
institution to release information about the disability, accommodations or special needs I have identified above to
Pitzer’s Office of Study Abroad and International Programs or the sponsor of my exchange program. I have read and
understood this form in its entirety and certify that the information I have provided is true.
Signature ______________________________________________ Date _______________________________________