REQUEST FOR REASONABLE ACCOMMODATIONS
COLORADO SCHOOL OF MINES
STUDENT DISABILITY SERVICES (SDS)
Please read the Documentation Guidelines on the website for CSM requirements.
All information obtained in diagnostic medical, psychological, and educational reports will be maintained and
used in accordance with applicable confidentiality requirements.
Name:
CWID:
Date of Birth:
Address:
Street, City, State, Zip:
Telephone #:
Mines Email address:
Other Email address:
Status:
Beginning Student
Transfer Student
Current Student
Semester/Year you will begin:
Semester/Year you will begin:
Semester/Year you began:
Please check all that apply:
Attention Deficit/Hyperactivity Disorder(s)
Autism Spectrum Syndrome
Brain Injury
Hearing Impairment
Learning Disorder(s)
Medical Condition
Mobility/Physical Impairment
Psychological Disorder
Visual Impairment
Accommodations you are seeking at CSM:
_____________________________________________________________________________________________________________________
RELEASE OF INFORMATION
If necessary in order for CSM to provide reasonable and effective accommodations, I hereby give permission
for SDS staff to discuss the documentation I have submitted with my physician, psychologist, or other qualified
professional, and to discuss my impairment with my parents and CSM faculty and professional staff. I
understand that my refusal to authorize consent may result in incomplete information and a denial of
accommodations.
Student Signature:
Return this form to:
Student Disability Services
W. Lloyd Wright Student Wellness Center, Room 205
Golden, CO 80401
Date: