Public Accommodation Request

* indicates a required field

Student Self-Report Form

Student Information

Please enter your information

Date of Birth Required

Contact Information

Please use your Lyon College issued email address

2300 Highland Road
Batesville, AR 72501

Please enter number in XXX-XXX-XXXX format.

Is the provided phone number above a mobile phone that is text-enabled?Required
If a text-enabled number, do you give permission to the following?Required
Receive occasional texts from the Office of Academic Support & Accessibility to deliver reminders pertaining to your accommodations?

Emergency Contact Information

(XXX) XXX-XXXX

Specialist/Physician Contact Information

Condition Information

Select all that applyRequired
{"display_name":"Select all that apply","hidden_field_name":"ms_field_1","init_id":"ms_field_1","init_link":"","has_autocomplete":false,"has_hierpicklist":null}
Has this condition affected you since birth?Required
Describe how you were diagnosed, your symptoms, and the ways in which your daily life and education are affected.

Reasonable Accommodations

Select the services that may apply. Not all services are applicable to all programs. Requested accommodations must be reasonable and directly relate to the barriers that arise as a result of your condition.

General Services
Testing Services
Classroom Services

Not all services are applicable to all programs. 

Emergency Procedures

Can you walk without assistance?Required
If you cannot walk without assistance, can you walk if assistance is provided?Required
Can you hear a fire alarm?Required
Can you maneuver stairs without assistance?Required
If you cannot maneuver stairs without assistance, can you maneuver stairs if assistance is provided?Required
Do you need to be carried?Required
Do you need assistance exiting a building?Required
Do you have seizures?Required
Do you have a health condition that required Lyon personnel to have special instructions or prior knowledge of the condition?Required

Documentation

In considering reasonable accommodations, it is often helpful to provide documentation from a qualified professional in the area in which the disability is diagnosed and who is not related to the student. Although documentation is not required to submit a self-report, it may not be possible to determine all possible reasonable accommodations without it. For guidance on appropriate documentation, go to https://www.lyon.edu/documentation-guidelines

Documentation Provided
504/IEP are applicable to the Batesville campus only.
Drop files here to upload

ATTESTATION & AGREEMENT

By signing below, I attest that all information in this self-report form is accurate to the best of my knowledge; I have read and understand Lyon College's Office of Academic Support & Accessibility Grievance Policy; https://www.lyon.edu/office-of-disability-services-grievance-policy; I give permission to Accessibility Officers to contact and discuss my condition and needs with appropriate school personnel including, but not limited to, advisor(s), professors, academic personnel, and other parties deemed necessary to have a justified interest in providing me reasonable academic accommodations and modifications at Lyon College.