BRYAN COLLEGE
Disability Accommodation Application
PLEASE NOTE: Students must meet with the ADA coordinator within the first ten days of classes each
semester in order to arrange accommodations. If a diagnosis is given in the middle of a semester, the
student must meet with the ADA coordinator within ten days of receiving documentation.
Name ____________________________________________________________________________
Address ___________________________________________________________________________
City ____________________________ State ____________________ Zip ______________________
Home/Cell phone _______________________________ Work phone _________________________
Date of birth ____________________ Email _____________________________________________
What are your disabilities and any functional limitations? __________________________________
_________________________________________________________________________________
What medications are you currently taking? _____________________________________________
_________________________________________________________________________________
What accommodations have you previously received? ____________________________________
_________________________________________________________________________________
What accommodations are you requesting at Bryan? _____________________________________
_________________________________________________________________________________
What diagnosis has been given? By whom and when? ____________________________________
_________________________________________________________________________________
Have you received services for your disability in previous educational settings? _________________
_________________________________________________________________________________
Please indicate which grades, 1-12, or year of college: ______________________________________
Have you attended a school that specialized in learning disabilities? Yes____ No ____
If yes, what school did you attend? Grades/years attended? _________________________________
Have you received any tutoring, counseling, or special therapy of any kind? Yes ____ No ____
If yes, by whom?
Tutor: ___________________________________________________
Dates: __________________
Learning Disabilities Specialist: ______________________________
Dates: __________________
Psychologist / Psychiatrists: _______________________________
Dates: __________________
Completion of this application does not ensure accommodations. Accommodations are based on review of
documentation specific for each disability and its impact and functional limitations.
DOCUMENTATION
Documentation is required to be on professional letterhead with the name, title, address, and phone
number of the professional.
Documentation should be current, preferably within the last three years. (The age of acceptable
documentation is dependent upon the disabling condition: i.e. older documentation may be accepted
for conditions that are permanent, etc.) If the student has existing or current documentation of their
disability from their health care provider or diagnostic professional, it may be attached to this section,
provided it meets these criteria.
Documentation must include specific diagnosis, description of the functional limitations that may affect
academic performance, rating of severity, recommendations for accommodations and medications
currently used and may only be from a physician, psychologist rehabilitation counselor, or social worker
who is qualified to assess the disability and is not related to the student. By signing this application, you
are granting permission to contact the author of documents submitted recommending
accommodations.
Signature ______________________________________________
Please send this application and required documentation to:
Traditional Students:
Bethany Smith, ADA Coordinator
Box 7800, 721 Bryan Dr.
Dayton, TN 37321
Phone: (423) 775-7173
Fax: (423) 775-7330
ATTN: Bethany Smith
bsmith6390@bryan.edu
Date: __________________