Request for Special Accommodation Student form

Confidentiality - Collection, use and disclosure of this information is subject to all applicable privacy legislation.

Name Name First Last
Email Address (de Souza User Name)
Current de Souza Course Requiring Accommodation
Nature of Condition/ Disability/ Disorder which requires accommodation
Maximum of 600 characters allowed. Currently Entered: 0 characters.
Accommodation Requested

Extra Time for;

Accommodation Requested

Extra Time for; Course Exam/Test Both
Other Accommodation
Please describe accommodation requested if not addressed by increasing time allowed
Please provide information about how your condition/disability/disorder would require accommodation and how this accommodation would mitigate that challenge. (you may attach a separate word document if you require more space)
Attach a Copy word document if you require more space.

Attach Files
Please note that we request that your health care provider complete and submit the Request for Accommodation Health Care Provider Form (https://forms.desouzainstitute.com/view.php?id=63618). Supporting information from a health professional must be submitted by the health care provider to de Souza Institute directly, via support@desouzainstitute.com or Fax: +1 (855) 712-0826.