Student Accommodation Services Request Form - Fairfax University of America

Name:*

First Last

Student ID:*

FXUA Email:*

Phone Number:

Date of Birth:

Academic Information

Current Class Standing:

Are you currently enrolled in courses at Fairfax University of America?

Major or intended course of Study

Support Services Information

My diagnosed disability falls into the following category:

Describe in your own words the limitations caused by the condition you have named

Describe how your condition affects your educational experience

What medications are you currently taking related to your condition(s)

If taking medication(s) what are their side effects?

Prior Support Services

Have you received academic accommodations in another setting?

Support Services Requested

Name the specific accommodations you are requesting and describe how they will enable you to be a successful student:

Do you have any additional comments?

Upload Support Documents

Upload Support Documents attachment.

Max. file size: 128 MB.

General Disability Documentation Guidelines:
General Disability Documentation Guidelines

Learning Disability Documentation Guidelines:

If you have any questions/concerns about this, please e-mail:
By clicking submit I understand the medical information I provided to the Student Accommodation Services shall be considered confidential. However, I also understand that limited disclosure to others in the University may be necessary in order to provide the services that I have requested through the Student Accommodation Services.

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