Student Intake Form

This is a secure, online request form for disability accommodations.

Reasonable accommodations are considered for students with a documented disability, under the Americans with Disability Act, as amended in 2008, to allow equal access to academic programs, activities, and services. Accommodations are determined by a student’s self-report, official medical documentation describing the current functional limitations a disability has on learning and life activities, and essential course and program elements.

To receive academic accommodations from Bellevue University you must register with the Accommodations Resource Center (ARC). To register you must provide official documentation from a licensed professional and complete this request form. A link to guidelines for documentation can be found below.

Please note ADA accommodations are not retroactive. They cannot be backdated and applied to previous work. They become effective once ARC sends notification to your professor(s).

All paperwork must be received before ARC can review your file to determine appropriate academic accommodations. If the appropriate professional is not immediately available, you can provide ARC with any unofficial diagnostic or medical documentation in your possession and ARC can consider the possibility for 45-day provisional accommodations to allow you time to collect appropriate documentation.

Once all paperwork is reviewed, an email will be sent to you that outlines proposed accommodations. You must give approval of the accommodations before your professor(s) are notified.

Your disability file is kept separate from your other University records. Other University officials who have a legitimate educational interest must contact ARC in order to access the file. Disability information is not included when notifying professor(s) of approved accommodations.

If you have documentation available to upload, you can upload it on this form.

If you have any questions about this form, please contact the Bellevue University Accommodations Resource Center at
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Student Information

Please enter your information
Date of BirthRequired
Please use your university issued email address
Do you currently live or plan on living in on-campus housing?Required
Have you previously received accommodations for your disability in an educational setting? During K-12 or at a previous college/university?Required
Are you a military veteran?Required

Supporting Information

FERPA – Disclosure of Information

The Accommodations Resource Center adheres to the Family Educational Rights Privacy Act (FERPA), which regulates the disclosure of documentation and records maintained by the Accommodations Resource Center. Under FERPA, the Accommodations Resource Center is permitted to release information to any University official who has a legitimate educational interest. Legitimate educational interest means the University official needs to review the record or receive related information in order to fulfill his or her professional responsibilities. The information shared will be the minimum needed for the official to fulfill his or her responsibilities. Sharing this information does not require student consent under FERPA. Prior written consent by the student is required before documentation or records are released to a third party.


The "Documentation Guidelines" document below outlines the information that is needed to document your disability. You may also submit any medical documents you have on hand that provide this information for review. Individualized Educational Plans (IEP) and 504 Plans can be submitted for review but may not be considered sufficient if they do not contain the needed information. Handwritten notes on prescription pads are not sufficient.

If you do not have documentation to provide at this time, you can submit it when you acquire it to the email, address, or fax number listed at the bottom of the "Documentation Guidelines" document. The document can be found here: Documentation Guidelines

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I hereby certify that the above statements and information are true and correct to the best of my knowledge. I certify that I am the student listed above and that this form is not being submitted on behalf of the student.