Disability Services Request Form

* indicates a required field

Information

The Office of Disability Services works closely with other College departments to provide appropriate aids and services for students with disabilities to ensure their full participation in all courses, activities, programs, and services.

The services provided help to:

-Remove barriers and identify accommodations to address individual student needs
-Support students in achieving academic, personal, and career goals
-Empower students with disabilities to become self-advocates
-Serve as a source of disability-related information for the College

Disability Services is located within the Learning Commons on the 2nd floor of Magale Library. You can reach them directly at disability@centenary.edu.

First NameRequired *

Last NameRequired *

Middle Name

Preferred NameRequired *

Student IDRequired *

EmailRequired *

Please use your Centenary issued email address

Phone NumberRequired *

Classification

Classification OtherRequired *

Are you requesting Academic Accommodations? Required *

Are you requesting Academic Accommodations? Yes Are you requesting Academic Accommodations? No

Please list the most recent school attended. Required *

Please indicate your major.Required *

If you haven't declared a major, enter "unknown"

I am requesting accommodations from Centenary College because I have been diagnosed with:Required *

check all that apply

Learning Disorder ADD/ADHD Mental Health Impairment Chronic Health Impairment Mobility Impairment Hearing Impairment Visual Impairment Autism Spectrum Disorder Traumatic Brain Injury Temporary Impairment Other

If you selected "other" above, please describe here:

Please list each accommodation that you are requesting, with an explanation. Please be as specific as possible. Required *

For example, if one of your requests is extended time for in-class exams, specify the amount of additional time (e.g., 1.5x)

Are you requesting Housing Accommodations? Required *

Are you requesting Housing Accommodations? Yes Are you requesting Housing Accommodations? No

Housing Accommodation Information

The vision and mission of Centenary College of Louisiana has established that all students enrolled are to reside on campus and share a room. Exceptions are made for those students that meet specified criteria. No requests will be processed or evaluated without proper documentation provided by your physician/provider.  Answer the following questions with as much detail as you are able to provide. The Office of Disability Services will send the Housing Accommodation Medical Form via email when your request is received.

Click on the following link to view important deadlines related to housing accommodation requests. https://www.centenary.edu/directories/offices-services-directory/vpaa-2/disability-services-2/housing-accommodations/

 *We will accept requests after the published deadline but space limitations means an approved request may not be fulfilled in the semester it is received.

Housing Accommodation RequestedRequired *

Please explain the reason the accommodation is requested/needed. Required *

Please indicate the type of disability this request pertains to (check all that apply)Required *

Physical Medical Mental Health Other

Housing Disability Other

Are you requesting an Emotional Support Animal Accommodation? Required *

Are you requesting an Emotional Support Animal Accommodation? Yes Are you requesting an Emotional Support Animal Accommodation? No

Emotional Support Animal Information

For a student to qualify to have an Emotional Support Animal on Centenary College’s campus, the student must have a disability as defined by the ADA and/or medical documentation that supports the need for an animal. Emotional Support Animals are considered a disability accommodation under the Fair Housing Act.

Students may qualify for an Emotional Support Animal (ESA) as an accommodation if

(1) the student has a documented disability
(2) the animal is necessary to afford the student with a disability an ability to fully participate in the campus housing; and
(3) there is a direct, identifiable, and documented nexus between the mental health impairment and the assistance provided by the ESA that mitigates one or more life activities.

Medical Providers must be certified/accredited in one of the following categories: MD, Ph.D., Psy.D., LPC and LCSW. Documentation provided by medical providers other than those listed will be considered on a case-by-case basis. Prescribing an ESA must fall within the provider’s scope of practice. The medical form must be signed by a practitioner who has an established and ongoing therapeutic relationship with the student and cannot be the student’s family member.

To view details regarding the ESA policy, application process, timelines/deadlines, etc., click here: https://www.centenary.edu/directories/offices-services-directory/vpaa-2/disability-services-2/animals-on-campus/emotional-support-animals/

ESA TypeRequired *

ESA Type Dog ESA Type Cat ESA Type Other

ESA Other TypeRequired *

Do you currently have possession of the animal?Required *

Do you currently have possession of the animal? Yes Do you currently have possession of the animal? No

I understand that I must obtain an official approval from Disability Services prior to bringing an animal on campusRequired *

Yes

Are you requesting a Service Animal Registration? Required *

Are you requesting a Service Animal Registration? Yes Are you requesting a Service Animal Registration? No

Service Animal Registration Information

For Service Animals, federal regulations do not require the individual with a disability to provide documented proof of training of the dog, nor do they have to provide documentation of their disability. Because Centenary is a residential institution, it is required that all students with a service animal to register with the Office of Disability Services as this allows ODS staff to communicate with other offices on campus that will help support the student (owner) of the service animal.

Is the animal required due to a disability?Required *

Is the animal required due to a disability? Yes Is the animal required due to a disability? No Is the animal required due to a disability? Maybe/Unsure

What task or duties is the animal trained to perform?Required *

Are you requesting a Meal Plan Accommodation? Required *

Are you requesting a Meal Plan Accommodation? Yes Are you requesting a Meal Plan Accommodation? No

Meal Plan Exemption Information

Meal Plan Accommodations are facilitated by Sodexo, via the Vice President for Finance and Administration's office (Robert Blue). Reach out to Linda Montgomery, Assistant to the VP of Finance and Administration, at lmontgomery@centenary.edu to get your accommodation request started.

You can find the Meal Plan Accommodation Form on this page: https://centenary.sodexomyway.com/my-meal-plan/index
Please note that you will need to obtain a password from the VP's office to access this form.

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