ADA/ESL Intake Form

* indicates a required field

ADA/ESL/Temporary Request Form

Submitting your documentation through this form will avoid delays in processing your requests.

Instructions

Any student requesting an ADA Accommodation and/or an ESL Testing Modification for the first time at the College of Law must fill out this form. Please use this form to request to register your Emotional Support Animal (ESA) or disclose your Service Animal. If you have already completed this form, please do not submit duplicate forms. Log into your Accommodate Account with your Stetson Credentials to renew or amend your request or contact the ADA Coordinator.

First NameRequired *

Last NameRequired *

Middle Initial

Personal Pronouns

She/Her/Hers, He/Him/His, They/Them/Theirs, etc.

Student IDRequired *

Your 800# with NO dashes and NO spaces

EmailRequired *

Please use your Stetson Law email address. If you are participating in a Study Abroad program, but attend another law school, please use your home law school email address.

Preferred Phone NumberRequired *

Month/Year of AdmissionRequired *

Intended Date of Graduation (Month/Year)Required *

ProgramRequired *

Status

Status Part-Time
Status Full-Time

Study Abroad or Semester ExchangeRequired *

If you selected the Study Abroad or Semester Exchange option above, please specify which program, including the dates. Otherwise, write N/A.

What semester or session are you requesting accommodations and/or modifications?Required *

You may only select one semester or session as every student must renew their accommodation and/or modification request each semester and session.

What type of Accommodations are you requesting?Required *

If you are requesting to register your Emotional Support Animal or you are disclosing your service animal AND are requesting additional accommodations, please select "ADA Accommodations or Temporary Accommodations" above. If you are only disclosing your Service Animal, but are not requesting any accommodations, please select "N/A - I am only disclosing my service animal."

What type of Accommodations are you requesting? N/A - I am only disclosing a service animal and requesting no additional accommodations
What type of Accommodations are you requesting? ADA Accommodations or Temporary Accommodations
What type of Accommodations are you requesting? English as Second Language Testing Modifications (for Non-English Speakers)
What type of Accommodations are you requesting? Both ADA/Temporary and ESL

Instructions:
Please review policy on Testing Modifications for Foreign Students at http://www.law.stetson.edu/policies before submitting this form. Please complete this form and submit to the ADA Coordinator by the date for Exam Accommodations listed on the Academic Calendar.

NOTE: This modification request must be renewed each semester. A testing modification for foreign students is not considered a disability accommodation under the Americans with Disabilities Act in accordance with Title III of the Americans with Disabilities Act of 1990 and ADA Amendments Act of 2008, and the Rehabilitation Act of 1973 (Section 504, as amended).

Please complete the following questions to determine your eligibility for ESL Testing Modification(s)

What is your native languageRequired *

How long have you lived in an English speaking country, whether consecutive or not?Required *

Have you attended an English language high school or university for at least one academic year?Required *

Have you attended an English language high school or university for at least one academic year? Yes Have you attended an English language high school or university for at least one academic year? No

Have you earned a degree with a major in the English language at a university?Required *

Have you earned a degree with a major in the English language at a university? Yes Have you earned a degree with a major in the English language at a university? No

Have you received testing modifications for ESL at any other U.S. Institution?Required *

Have you received testing modifications for ESL at any other U.S. Institution? Yes Have you received testing modifications for ESL at any other U.S. Institution? No

If yes, please explain

Do you have any other information you feel relevant for the ADA Coordinator to consider?Required *

Types of information could include explanations to the YES/NO responses above, English Proficiency Testing Scores, etc.

ESL Testing Modification PolicyRequired *

By checking this box, I certify that I have read the Testing Modifications for Foreign Students policy located on Stetson Law's website.

I have read the Testing Modifications for Foreign Students policy.

ESL Testing Modification DisclaimerRequired *

By checking this box, I understand that an ESL Testing Modification for foreign students is not considered a disability accommodation under the Americans with Disabilities Act in accordance with Title III of the Americans with Disabilities Act of 1990 and ADA Amendments Act of 2008, and the Rehabilitation Act of 1973 (Section 504, as amended).

I understand that an ESL Testing Modification for foreign students is not considered a disability accommodation under the law.

Are you opting to disclose a Service Animal?Required *

Under the ADA Amendments Act of 2008, there are only two breeds of service animals: a dog or a miniature horse.

Are you opting to disclose a Service Animal? Yes Are you opting to disclose a Service Animal? No

Is the service animal required because of a disability?Required *

Is the service animal required because of a disability? Yes Is the service animal required because of a disability? No

What work or task has the service animal been trained to perform?Required *

Do you reside in Stetson Housing?Required *

Registration fees for service animals are waived.

Do you reside in Stetson Housing? Yes Do you reside in Stetson Housing? No

Is there anything else you would like to share about your service animal?

While not required, the animal's name, breed, and suggestions for student, staff, and faculty interaction, etc. to assist in proving you support.

Are you requesting to register an Emotional Support Animal (ESA)?Required *

Documentation from a licensed health care provider (e.g. physician, psychologist, licensed mental health counselor, nurse practitioner, whom has experience and training in the field of disability) is required to determine the eligibility of this request. You may find the ESA Accommodation Request Form on the Accessibility Resources web page and in your Accommodate document library after submitting this intake form.

Are you requesting to register an Emotional Support Animal (ESA)? Yes Are you requesting to register an Emotional Support Animal (ESA)? No

Describe the ESA's breed, name, and size.Required *

Do you reside in Stetson housing, on or off campus?Required *

Do you reside in Stetson housing, on or off campus? Yes Do you reside in Stetson housing, on or off campus? No

ESA Accommodation Request Form, Proof of Vaccinations, License Registration, and Veterinary Letter of Health:Required *

The ESA Accommodation Request form completed by a qualified medical provider must be submitted. You may find a copy of the form on our Accessibility Resources Animal Policy web page. Proof of vaccinations and license registration are also mandatory. The Veterinary Letter of Health is only required if the animal is not a dog or cat.

By checking this box, I agree to bring the appropriate documentation to the initial meeting with the ADA Coordinator or submit it with this intake form. Failure to bring the required documentation may result in a delay in approving or denial of my request.

Describe the nature of your disability. Required *

This is a required field. If you are only disclosing a service animal, you may put n/a.

How long have you had a diagnosis of your disability? Required *

How long have you had a diagnosis of your disability? N/A - I am only disclosing a service animal.
How long have you had a diagnosis of your disability? 1 year or less
How long have you had a diagnosis of your disability? 2 years
How long have you had a diagnosis of your disability? 3 years
How long have you had a diagnosis of your disability? 4 years
How long have you had a diagnosis of your disability? 5 or more years
How long have you had a diagnosis of your disability? Most of my life

How long have you experienced symptoms of your disability?Required *

How long have you experienced symptoms of your disability? N/A - I am only disclosing a service animal.
How long have you experienced symptoms of your disability? 1 year or less
How long have you experienced symptoms of your disability? 2 years
How long have you experienced symptoms of your disability? 3 years
How long have you experienced symptoms of your disability? 4 years
How long have you experienced symptoms of your disability? 5 or more years
How long have you experienced symptoms of your disability? Most of my life

Describe your prognosis.Required *

Describe your prognosis. N/A - I am only disclosing a service animal.
Describe your prognosis. Stable
Describe your prognosis. Degenerative
Describe your prognosis. Likely to Improve but not fully resolve
Describe your prognosis. Unknown
Describe your prognosis. Temporary

Describe how your disability impacts activities central to your daily life. Required *

This is a required field. If you are only disclosing a service animal, you may put n/a.

Describe how your disability impacts you academically, including in the classroom and on any assessments or exams.Required *

This is a required field. If you are only disclosing a service animal, you may put n/a.

What, if any, mitigating measures do you take to lessen the impact of your disability?Required *

This is a required field. If you are only disclosing a service animal, you may put n/a.

Does an outside agency provide you assistance?Required *

Does an outside agency provide you assistance? N/A - I am only disclosing a service animal.
Does an outside agency provide you assistance? No
Does an outside agency provide you assistance? Yes

If yes, please identify each agency and the assistance to be provided.Required *

Have you received accommodations at a previous college or university?Required *

Have you received accommodations at a previous college or university? N/A - I am only disclosing a service animal.
Have you received accommodations at a previous college or university? No
Have you received accommodations at a previous college or university? Yes

If yes, please list the accommodation(s) you previously received.Required *

This is a required field. If you are only disclosing a service animal, you may put n/a.

Were you previously granted accommodation(s) for standardized testings (e.g., LSAT, SAT, ACT)?Required *

Were you previously granted accommodation(s) for standardized testings (e.g., LSAT, SAT, ACT)? N/A - I am only disclosing a service animal.
Were you previously granted accommodation(s) for standardized testings (e.g., LSAT, SAT, ACT)? No
Were you previously granted accommodation(s) for standardized testings (e.g., LSAT, SAT, ACT)? Yes

If yes, please identify the test(s) and describe the accommodation(s) received.Required *

This is a required field. If you are only disclosing a service animal, you may put n/a.

Select the type(s) of accommodation(s) you are requesting to receive at the College of Law.Required *

Please select one or both, if applicable. If you are requesting to register an Emotional Support Animal or disclosing a Service Animal, please select NON-Exam Accommodation.

N/A - I am only disclosing a service animal.
NON-Exam Accommodation
Exam Accommodation

Describe the accommodation(s) you are requesting at the College of Law. Be as specific as possible.Required *

Please list each request on a separate line.

Submit supporting documentation.

You may also hand-deliver or email your documents to ada@law.stetson.edu for the ADA Coordinator to review. **Document submission may be vital to the decision-making process; failure to submit relevant documentation may delay the granting of reasonable accommodations.

Documentation GuidelinesRequired *

I acknowledge I have read the "Documentation Guidelines" located on the College of Law's Accessibility Resources webpage.

I have reviewed the Documentation Guidelines.

Reasonable Accommodations and Standards for Law StudyRequired *

I acknowledge I have read the "Reasonable Accommodations and Standards for Law Study" located on the College of Law's Accessibility Resources webpage.

I have reviewed the Reasonable Accommodations and Standards for Study of Law.

College of Law Policy: Guidelines for Animals on Campus-Gulfport.Required *

By checking the box below, I certify that I have read and understood the College of Law's Guidelines for Animals on Campus-Gulfport.

I agree to comply with the College of Law's Guidelines for Animals on Campus-Gulfport.

Guidelines for Animals on Campus-Gulfport:Required *

By checking the box below, I certify that I have read and understood the College of Law's Guidelines for Animals on Campus-Gulfport.

I agree to comply with the College of Law's Guidelines for Animals on Campus-Gulfport.

Consent For the Purpose of Disability Support:Required *

By checking this box, I give my permission and consent for Stetson University College of Law to receive this information and to determine whether pertinent faculty and staff members should be informed of my disability information for the purpose of fully supporting my needs.

Certification - Step 1:Required *

By checking this box, I certify the above statements are true and correct. I acknowledge that any misrepresentation made on this form can be grounds for an Honor Code Proceeding.

Certification - Step 2: Required *

Type your full name.

ADA/ESL Intake Form

ADA/ESL/Temporary Request Form

Document Information