Confidential Registration Form

Student Information

***The student is responsible for completing the Confidential Registration Form. If anyone other than the student completed the CRF, the form will be rejected and the student will be asked to complete the Confidential Registration Form again, which will delay the registration process***

Under Section 504 of the Rehabilitation Act and the Americans with Disabilities Act (ADA), Monmouth University is mandated to make reasonable accommodations for otherwise qualified students with disabilities. Accommodations are determined on a case-by-case basis by the Department of Disability Services.

To receive accommodation/services, verification of a disability is required. All information will be treated confidentially and released only to appropriate personnel on a need-to-know basis. To access accommodations/services, individuals must initiate a request for specific accommodations/services.

• Accommodations are not retroactive; it is best to request accommodations before an issue arises.

• Requesting accommodations does not guarantee their approval.

• Final determination will be made by the Department of Disability Services.

Legal First Name

Legal Last Name

Preferred Name

Preferred Pronouns

He/She/Them

Email

If you have a Monmouth University issued email, please use it here.

Cell Phone Number

Home Phone Number

Emergency Contact Name

Emergency Contact Phone Number

Are you a current Monmouth student or paid your deposit to attend Monmouth?

Semester Start

Please choose the Semester you wish to start using the requested accommodation(s).

Tell Us About Yourself

How were you referred to DDS?

Why are you contacting DDS

Pick all the apply

Diagnosis

Specific Accommodation Information

Please describe your formal diagnosis and how your disability impacts you as a student:

Academic Information

Which aspects of learning do you find the most challenging?

Academic Accommodations

Please list the requested accommodations that you feel are necessary to allow you to access our curriculum and community

Other Information

Do you currently, or plan to live in MU housing?

Please check all that apply

Please include anything else you would like DDS to know in order to best assist you

Please list any questions you have about our services

Documentation

Students requesting academic accommodations who are also under the care of a physician, clinician or other specialist should have their treating clinician complete and submit the Monmouth University Academic Provider Form.

Required documentation (grade 12 IEP or 504 Plan) must be current and Child Study Team testing (copies of educational and psychological reports) must be from chronological age 16.5 or later. The student must present a diagnosis or a disability as defined by the Americans with Disabilities Act (ADA) and Section 504 of the Rehabilitation Act of 1973.

Students who need to request housing, meal plan or parking accommodations should contact the DDS Office via email at DDS@monmouth.edu.

Documentation must be uploaded in PDF format. Documentation not in PDF format will cause delay in processing.

Upload supporting document(s)

Please only submit this form one time. If you have questions about your submission contact the Department of Disability Services for Students at 732-571-3460 (voice) or DDS@monmouth.edu.