THE COLORADO SCHOOL OF MINES
Disability Services
REQUEST FOR CONSIDERATION FOR REASONABLE ACCOMMODATIONS
All information obtained in diagnostic medical, psychological, and educational reports will be maintained and used in accordance with applicable
confidentiality requirements. Please read the Documentation Guidelines on the website for CSM requirements.
Name _____________________________________________________________
CWID ________________________
Date of Birth ___________________
Address ____________________________________________________________
Street, City, State, Zip
___________________________________________________
Telephone # ______________________ Mines Email address
____________________
Other Email address ____________________
Status
Beginning Student
Transfer Student
Semester/Year you will begin:
_______/_______
Current Student
What is the nature of your Impairment? (Check all that apply. Please attach additional
pages if necessary.)
Learning Disorder(s)
Attention Deficit/Hyperactivity Disorder(s)
Blindness or Low Vision
Deafness or Hearing Loss
Asperser’s Syndrome
Mobility/Physical Disorder (please explain nature of disability)
_________________________________________________________________________________________
_______________________________________________________________________________
Psychological Disorder (please explain nature of disability)
_________________________________________________________________________________________
_______________________________________________________________________________
Brain Injury (please explain nature of disability)
_________________________________________________________________________________________
_______________________________________________________________________________
Medical Disability (please explain nature of disability)
_________________________________________________________________________________________
_______________________________________________________________________________
Please list the accommodations you received in high school and those you may request at CSM. (Attach additional pages if necessary.)
Accommodations you received in high school: ________________________________________________________________________
____________________________________________________________________________________________________________
Accommodations you may request at CSM: ___________________________________________________________________________
___________________________________________________________________________________________________________
RELEASE OF INFORMATION
In order to explore possible coverage and reasonable accommodations, it is often necessary for the Disability Services staff to discuss the
documentation the student has submitted to our office with providers such as licensed physicians, psychologists, or other qualified professionals, and
to discuss the student’s impairment with their parents and Colorado School of Mines’ faculty and professional staff. I hereby give permission for
Disability Services at the Colorado School of Mines to exchange information regarding the documentation I have submitted to the Office of Services
for Students with Disabilities with my provider(s) (physician, psychologist, or other qualified professional), and to discuss my impairment with my
parents and Colorado School of Mines faculty and professional staff. I understand that my refusal to authorize consent may result in a denial of
accommodations.
___________________________________________________________ _____________________
Student Signature
Date
Return this form to: Kristen Wiegers
Student Services Specialist--Student Development and Academic Services
1600 Maple St., Suite 8, Colorado School of Mines, Golden, CO 80401
www.mines.edu/stu_life/dss