Accommodations Request Form

Please complete the following information to request accommodations.


Name *

Cell Phone Number

Home Phone Number

I am requesting accommodations for the following semester *

Will you be graduating this semester? *

Are you taking any online courses this semester? *

Student Accommodations Statement

  1. Student accommodations will be the same each semester, unless there are changes in the disability, and related needs are discussed with Cassandra Jones, Assistant Director of Disability Services. If you have questions and would like to speak with someone about your accommodations, please call the Learning Assistance Center at (513) 745-3280.
  2. Students must pick up their Student-Faculty Agreement from the LAC to take to each of their professors.
  3. It is recommended that students schedule appointments to meet with their professors as soon as possible during the first three weeks of the semester or prior to their first scheduled exam.

The following should be discussed at the meeting with your professor:

  1. Accommodations you are eligible to receive and how they apply to the course format.
  2. Responsibilities you and your professor will each share in order to receive/provide outlined accommodations.
  3. Review the Student-Faculty Agreement and sign off on the form.


By agreeing to the terms and conditions, and submitting the form, I am authorizing the Learning Assistance Center to communicate with other offices and personnel that may be involved with my academic accommodations at Xavier. I understand that this communication will allow the LAC to better serve my needs. I certify that I have completed this form to the best of my ability and that all information is accurate and have reviewed the Student Accommodation Statement Above.