Disability Disclosure Form

Please only complete this form if you want to log your disability/disorder with the Office of Student Affairs and/or you are requesting accommodations for the upcoming Academic School year. If you have any questions when completing the form, please email student affairs@relay.edu.

Relay strives to create an inclusive and safe learning environment for all of our students. The Office of Student Affairs is here to help you to demonstrate the existence of an exceptionality which may entitle you to reasonable accommodations, services and supports under the Americans with Disabilities Act (ADA) and related laws. The information you submit on this form will be shared with the Office of Student Affairs who will then review your request and follow up with you as appropriate.

Please note that if you select "No Accommodations Required," you will not receive a follow-up request for a meeting as this indicates you are not in need of supports at this time.

First Name or Preferred Name*

Last Name*

Middle Initial

Email Address (most accessible email)*

Relay Location*

Select or enter value

Current Advisor Name

Expected Graduation Year*

Select or enter value

The category that best describes your condition #1*

Select or enter value

The category that best describes your condition #2*

Select or enter value

The category that best describes your condition #3*

Select or enter value

Please describe your condition:*

Do you have a mobility concern?*

that would prevent you from evacuating a building in an emergency?

Select or enter value

Other - Please describe:

In the past, have you required accommodations?*

Select or enter value

If yes, what accommodations did you require?*

Describe the accommodation(s) that you request*

Please note that at this time Relay cannot provide personal care attendants, personal readers/notetakers, or personal devices.

Medical Documentation

Relay Graduate School of Education is required to obtain documentation from a treating healthcare professional supporting your disability or disorder. Documentation from external sources may include educational or medical records, reports and assessments created by health care providers, school psychologists, therapists, teachers, or the educational system. This information is inclusive of documents that reflect education and accommodation history, such as Individual Education Program (IEP), and or relevant Section 504 Plans xii. The documentation should be a typed on letterhead: Dated within 12 months of today's date, State the disability or disabilities. Explains the need for the requested accommodations (If appropriate) Discusses the severity and/or expected progression (If appropriate) Lists potential side-effects of relevant medication (If relevant) Describes current and/or past accommodations and signed by a qualified professional. Please ensure that your document is 2MB or less. You may upload up to 3 documents. If your document(s) are too large, please email them directly to studentaffairs@relay.edu. Do not email any documents to instructors or professors. **You can continue to complete this form but please note that your missing documentation can delay the accommodations process and/or may result in the request being denied or voided. We would advise you set up a time to speak with someone in the Office of Student Affairs.

Do you have medical records to support your claim?*

Select or enter value

By signing my name below, I acknowledge that:*

by not providing medical documentation, my request for accommodations may be denied or experience delay as a result.

Medical Document Upload

Drag and drop files here or

By signing my name below, I confirm:*

I DO NOT NEED accommodations for the 2021-2022 school year. Please email the Office of Student Affairs (studentaffairs@relay.edu) if you have any questions and/or would like to have your accommodations request(s) revisited.

By signing my name below, I understand:*

In order to be granted accommodations, I must comply with Relay’s procedure for confirming the need for accommodations. To access services, I must initiate this request in writing (this form), and, be granted specific services/accommodations. Relay may ask for written permission to communicate with my doctor and/or evaluator regarding the disability and identified accommodations. Accommodations requests are evaluated and determined on a case-by-case basis. Relay may not grant accommodations that – - substantially alter the educational standards or mission of Relay - fundamentally alter the nature of the program, course, service, activity, and/or practice/policy as written and applied; - allow access to a program when a student is not otherwise qualified (with or without accommodations) to meet the academic and technical standards required for admission or participation in an education program, course, service and/or activity; - cause undue financial or administrative hardship (university-wide); - be of a personal service in nature (personal aid, study coach, individually paid tutor, etc.); pose a direct threat to the health or safety of the student with a disability or others as a result of accommodation implementation. I understand that my accommodation request may be shared with my campus instructors/advisors. I may be asked to meet with a representative of the Office of Student Affairs in response to this disclosure. Registering with the Office of Student Affairs by submitting this form does not signify that Relay considers me disabled, or that a specific accommodation will be granted. I take full responsibility for ongoing assistance.

Please note that if you select "No Accommodations Required," you will not receive a follow-up request for a meeting as this indicates you are not in need of supports at this time.

Send me a copy of my responses

Privacy Notice|Report Abuse

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.