REQUEST FOR
ACCOMMODATIONS
Date of Request: mm/dd/yyyy
In order to determine the appropriate CTY Summer Program accommodations for your child and to
ensure their timely implementation, please complete this Request Form by May 15 or earlier, if
possible. Appropriate documentation may be submitted along with your request. Documentation
guidelines can be accessed at: http://cty.jhu.edu/disability/documentation/
Please note that you must contact CTY’s Disability Services Administrator at melissa.kistler@jhu.edu if
your child changes programs/courses after submission of this request form to ensure the appropriate
information reaches the correct site staff.
STUDENT INFORMATION
Student’s Full Name: Student name (first, last)
Site: Enter Site Name
Session: Enter Session(s)
Course: Course title
Student CTY ID Number: Enter Student ID
Parent/Guardian’s Name: Full Name Of
Parent/Guardian
Parent/Guardian’s Phone Enter Main Phone Contact
Info
Parent/Guardian’s Email: Enter Email Contact Info
Privacy Statement: The privacy rights of students with disabilities/special needs are honored to the fullest
extent possible. This request and any accompanying documentation are maintained in secure files separate from
a student’s regular CTY records. Disability-related information and documentation are treated in a confidential
manner and shared only on a need-to-know basis.
STRENGTHS AND AREAS OF IMPAIRMENT
1. What are the student’s strengths?
2. What is the nature of the student’s disability, including the diagnosis?
3. Please describe the current limitations the disability causes for the student’s work in class and
outside of the classroom:
ACCOMMODATIONS REQUESTED: (Please include information on any special emergency
evacuation preparations or procedures that may be needed.)
1. List accommodations requesting for the academic environment
2. Has the student received these accommodations in the past?
CTY Disability Services will review submitted documentation and your request for accommodations and/or support and, in
coordination with Johns Hopkins University’s Director of ADA Compliance and Disability Services will determine
accommodations and/or supports that CTY will provide for your child while attending CTY Summer Programs. You have the
right to appeal this determination with JHU’s Office of Institutional Equity if you believe a reasonable accommodation has
been denied.
Page 1
Please return this Request Form to CTY Disability Services:
Email: melissa.kistler@jhu.edu
Fax:
410-800-4060 (This only goes directly to CTY Disability Services.)
Mail:
ATTN: Melissa Kistler
Johns Hopkins Center for Talented Youth
McAuley Hall, Ste. 400
Baltimore, MD 21209
*Please note that in order to receive the requested accommodations in additional courses/programs; you
must submit a new Request for Accommodations form and/or be in contact with CTY Disability Services prior
to beginning the new course/program. Accommodations and disability information does not automatically
follow a student into future courses/programs without direct consent from the parent/guardian and different
courses/programs may require additional or less accommodation.
*More information about CTY Disability Services and transitioning to summer programs (for students with
ADHD, Asperger’s/ASD, mental health concerns, and/or learning disabilities can be found at the Summer
Programs Disability Services webpage.
SEE NEXT PAGE FOR ADDITIONAL OPTIONAL PORTION OF THE FORM
Page 2
OPTIONAL: FURTHER INFORMATION AND REQUESTS FOR
OTHER SUPPORTS
(This section is OPTIONAL. Please just check the appropriate boxes if no support is requested.)
The chart below is to help you think about further information to provide us with and what supports (in
conjunction with or in addition to the requested accommodations) may help your child succeed in the
CTY Summer Program. If you addressed a particular need in the Accommodations Request portion of
this form, please feel free to just note this in the appropriate section below.
Aspect of program that students are
expected to handle during the course
of the summer.
Please describe the support that you are
requesting to help your child manage this aspect
of the program.
Social
Self-monitoring – consider managing
self during unstructured time in
activities and/or class breaks
(begin typing here)
Managing social interactions – consider
situations when student may feel
overwhelmed, frustrated, or angry
(begin typing here)
Participating in group activities –
consider large and small group
activities both in and out of class
(begin typing here)
Not disrupting class, recreational
activities, or student meetings
(begin typing here)
Academic
Sitting and paying attention in class and
following directions
(begin typing here)
Managing assignments and completing
work – consider completing writing
assignments, taking tests, etc.
(begin typing here)
General
Transitioning from one location to the
next or handling changes to routine
(expected and unexpected)
(begin typing here)
Meeting expectations for student
conduct (see attached)
(begin typing here)
Evacuating for fire drill or emergency –
what preparations or procedures need
to be considered?
(begin typing here)
Page 3
Check here if
no supports
are
requested
Other – please be as specific as possible
considering both academic and
residential/social contexts
(begin typing here)
EXPECTATIONS FOR STUDENT CONDUCT
We expect our students to meet the highest standards of behavior, both in personal deportment
and in dedication to academic pursuits. At each site, students learn about our standards for
behavior, including site rules, on the first day. While specific rules vary somewhat from site to site,
community standards throughout our summer programs are basic and consistent. They apply both
in and out of the classroom. They include a commitment to academic and personal integrity, respect
for all members of the community, regard for the basic rules of physical safety, and cooperation
with adult supervision. To this end, students must adhere to our Honor Code (see below).We
cannot accommodate students who are unwilling or unable to live up to these expectations. Please
discuss the meaning of this code with your child.
Center for Talented Youth Honor Code
CTY’s summer programs provide a unique opportunity for intellectually curious people from
diverse backgrounds to come together in pursuit of academic challenge and growth, within a
supportive community built on respect, responsibility, and trust. In order to create and sustain such
a community:









I promise to uphold academic and personal integrity, respecting the ideas and property of
others, and to ensure that those around me do the same; and
I promise to follow the Expectations for Student Conduct:
Strive to do the best academic work possible.
Respect individuals of different races, cultures, religions, genders, sexual orientations, ages,
disabilities, and national origins.
Behave in a friendly, cooperative, safe, and responsible manner toward all persons in the
CTY community and in the larger campus and local communities.
Attend all class sessions, meals, activities, and meetings.
Take responsibility for my own work and actions.
Cooperate with adult supervision.
Observe rules for physical safety and all other rules for student conduct.
I understand that my actions will shape our site community, and that my membership in the
community depends on my honoring this code.
Page 4