Disability Support Services Registration Form

Student Information

Please enter your information

First NameRequired *

Last NameRequired *

Middle Name

Preferred Name

Student IDRequired *

EmailRequired *

Please use your university issued email address

Phone NumberRequired *

Were you referred to DSS?

Were you referred to DSS? Yes Were you referred to DSS? No

Referral source

Guardian Contact Information

Name and contact information

Guardian 2 Contact Information

Guardian 3 Contact Information

Academic Accommodations Application

Are you requesting Academic Accommodations?Required *

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

My diagnosed disability falls into the following categoryRequired *

How does your disability affect you academically?Required *

How does your disability affect student life in general, like taking tests and studying?

What accommodations have you received in the past?

What academic accommodations are you requesting at Lehigh?

Housing Accommodations Application

Do you need to request housing accommodations?Required *

Do you need to request housing accommodations? Yes Do you need to request housing accommodations? No

Disability Housing Accommodations Information

Please visit the Disability Housing Accommodations Information page to learn more about requesting Disability Housing Accommodations.

Current Room Assignment (if applicable):

Semester for which the accommodation is sought:Required *

Year for which the accommodation is sought:Required *

Select One:Required *

Specify your Disability

Blind or low vision Physical or mobility chronic health condition deaf or hard-of-hearing psychiatric autism spectrum disorder Other (explain below)

Other

Is this request due to a temporary injury?Required *

Is this request due to a temporary injury? Yes Is this request due to a temporary injury? No

Please indicate expected duration:Required *

Have you previously applied for disability accommodations?Required *

Have you previously applied for disability accommodations? Yes Have you previously applied for disability accommodations? No

When did you receive accommodations previously, and what were the accommodations you received?Required *

What accommodations are you requesting? Required *

Requests must be supported by disability documentation.

Wheelchair accessibility air-conditioning semi-private bathroom strobe fire alarm assistance/emotional support animal (please see policy) single room kitchen facilities meal plan modification Other (please specify below)

If Other, please explain

Parking and Transportation Accommodations Application

Do you need to request transportation accommodations?Required *

Do you need to request transportation accommodations? Yes Do you need to request transportation accommodations? No

Do you need request parking accommodations?Required *

Do you need request parking accommodations? Yes Do you need request parking accommodations? No

Parking and Transportation Accommodations Information

Please visit the Parking and Transportation Accommodations Information page to learn more about requesting Parking Accommodations.

Briefly describe your functional limitations:Required *

i.e., how your condition impacts your need for alternate parking and/or transportation arrangements

What, if any, educational program, activity, or benefit are you having difficulty accessing?Required *

What limitation interferes with your access to educational programs, activities, or to access an educational benefit?Required *

What is the expected duration of your condition?Required *

i.e., how long do you believe that you will need the requested accommodation?

Have you had any accommodations in the past for this same limitation?Required *

Have you had any accommodations in the past for this same limitation? Yes Have you had any accommodations in the past for this same limitation? No

What were your previous accommodations and how effective were they?Required *

If you are requesting a specific alternative arrangement, how will it assist you?

Do you currently park on campus?Required *

Do you currently park on campus? Yes Do you currently park on campus? No

Please describe where you currently park.Required *

Where are you requesting to park?Required *

Information on campus parking zones is available at: Campus Parking Zone Map , or Campus Parking Zone Map - Text Version

Are you requesting a temporary or permanent parking changeRequired *

Are you requesting a temporary or permanent parking change Temporary Are you requesting a temporary or permanent parking change Permanent

Please indicate the anticipated start and end dates.Required *

Do you have a state-issued disability parking permit?Required *

Do you have a state-issued disability parking permit? Yes Do you have a state-issued disability parking permit? No

Do you require assistance traveling from your vehicle to other campus locations?Required *

i.e. your residence hall, classrooms, dining halls, etc.

Do you require assistance traveling from your vehicle to other campus locations? Yes Do you require assistance traveling from your vehicle to other campus locations? No

Please explain.Required *

Do you require assistance traveling between different places on campus?Required *

Do you require assistance traveling between different places on campus? Yes Do you require assistance traveling between different places on campus? No

Please explain. Required *

Can you wait for a bus at a bus stop, parking garage, etc.?Required *

Can you wait for a bus at a bus stop, parking garage, etc.? Yes Can you wait for a bus at a bus stop, parking garage, etc.? No

Please explain. Required *

Can you ride a bus?Required *

Can you ride a bus? Yes Can you ride a bus? No

Please explain. Required *

Are you able to walk?Required *

Are you able to walk? Yes Are you able to walk? No

What is the maximum distance you can reasonably be expected to walk?Required *

Do you use a wheelchair or scooter?Required *

Do you use a wheelchair or scooter? Yes Do you use a wheelchair or scooter? No

Can you climb stairs?Required *

Can you climb stairs? Yes Can you climb stairs? No

Please explain. Required *

Documentation

Lehigh Documentation Guidelines

Please choose this link to access Lehigh University's documentation guidelines.

Upload supporting document(s)

Disability Support Services Registration Form

Student Information

Academic Accommodations Application

Housing Accommodations Application

Parking and Transportation Accommodations Application

Documentation

Document Information