Application for Reasonable Accommodations

Thank you for submitting your application to Baylor's Office of Access and Learning Accommodation. If you have any questions, feel free to call us at 254-710-3605.

*Indicates Required Field

*Personal Information

First Name:
Last Name:
Baylor ID#:
Phone:	( ) -
Email:
Date of Birth:	ex. (08/08/2012)
Gender:	Female \|\| Male
Local Address
Address:
City:
Zip:
Home Address
Address:
City:
State:
Zip:

*Disability Related Information

Disability Category (please check all that appy and list specific diagnosis with date of last diagnosis next to indication):
	Specific Learning Disability	Diagnosis:	Date:
	Mobility	Diagnosis:	Date:
	Visual	Diagnosis:	Date:
	Psychological	Diagnosis:	Date:
	Cognitive	Diagnosis:	Date:
	ADD/ADHD	Diagnosis:	Date:
	Seizure	Diagnosis:	Date:
	Hearing Impaired	Diagnosis:	Date:
	Medical Condition	Diagnosis:	Date:
	Physical	Diagnosis:	Date:
	Orthopoedic	Diagnosis:	Date:
	Temporary	Diagnosis:	Date:

Specific accommodations requested (accommodation request MUST be included):

Type of medications related to disability:

If you would like to upload your medical documentation at this time, please attach your file below.
Document Types

Academic Information

	I am currently admitted to Baylor University
	I am an Incoming Student	Anticipated date of enrollment:	ex. (08/08/2012)
Academic Status
	Freshman
	Sophomore
	Junior
	Senior
Academic School
	Undergraduate
	Graduate
	Law
	Non-Degree or Continuing Education
Academic Major:

Military Information

	Active duty
	Veteran

Access and Learning Accommodation
One Bear Place #97204
Waco, TX 76798
254.710.3605
254.710.3608 (fax)