2013-14 Disabilities Registration Form for Study Abroad Programs
This form is to be completed by the student.
Although Goucher works with many educational institutions and program providers to provide study abroad opportunities to its students, Goucher cannot guarantee that accommodations that the student requests will be available in all programs and countries. Study abroad programs evaluate requests for accommodations on an individual basis. This form is intended to help the programs determine if they can meet the student’s needs.
Appropriate documentation will help the student to better understand his/her learning needs in a higher education setting and will assist the student and the study abroad program in making informed decisions about academic accommodations. For students with learning disabilities and/or attention deficit disorders, a psycho-educational evaluation may be required. (Documentation of Learning
Disability and/or Attention Deficit Disorder.)
Students with physical and/or sensory disabilities are encouraged to submit appropriate medical or clinical documentation, including a diagnosis and prognosis by a qualified physician, prescribed therapy and recommended academic adjustments and auxiliary aids.
This form and documentation and diagnosis of a specific disability completed by a qualified examiner should be mailed to Frona Brown, Disabilities Specialist, Goucher College, 1021 Dulaney Valley Road,
Baltimore, MD 21204 ( Frona.Brown@goucher.edu
) as soon as you are admitted to a study abroad program. The disabilities specialist and OIS will work with you and the program site to determine necessary accommodations and whether they are available in the program you have chosen.
If you have any questions or require additional information, please contact Dr. Brown at
Frona.Brown@goucher.edu or 410-337-6178.
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Student’s name:_________________________
Telephone number:______________________
Possible major(s):________________________
Student’s e-mail address:__________________
Student’s address:________________________
Disability (be specific):
_____________________________________________________________________________________
_____________________________________________________________________________________
November 2013

Please attach all documentation supporting your request for accommodations under Section 504 of the
Rehabilitation Act of 1973 and the Americans with Disabilities Act and provide the information requested below.
_____________________________________________________________________________________
Name of evaluator:________________________________ Telephone number:____________________
Dates of evaluation: _______________________________
Address of evaluator:___________________________________________________________________
Summarize the requested academic accommodations as stated in your documentation.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Thank you for your cooperation.
November 2013