An accommodation request should be submitted and approved before the student starts work on each course. While accommodation requests are usually processed within two weeks, some may take longer. For more information, please see BYU Independent Study’s Accessibility and Accommodations Policy. Please email any questions to email@example.com. Please complete and submit this form along with supporting documentation of disability from a qualified healthcare professional. If the student attends secondary school, the student’s school counselor or parent/guardian should submit the student’s IEP or 504 Accommodations Plan. Requests for accommodations must be specific. Submitted documentation must be dated within the last three years. Student Information Full Name * Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19231924192519261927192819291930193119321933193419351936193719381939194019411942194319441945194619471948194919501951195219531954195519561957195819591960196119621963196419651966196719681969197019711972197319741975197619771978197919801981198219831984198519861987198819891990199119921993199419951996199719981999200020012002200320042005200620072008200920102011201220132014201520162017201820192020202120222023 Net ID * Course Name * Course Code * (i.e. MATH 101) School Information School Name * Counselor * Address * City, State, ZIP/Postal Code, Country * Parent/Guardian Information Name * Phone * Email * Details of the Request Briefly describe the diagnosis or disability * Specific accommodations being requested for your Independent Study Course * Supporting Documents Files must be less than 5 MB.Allowed file types: jpg jpeg png pdf doc docx. Supporting Documents Files must be less than 5 MB.Allowed file types: jpg jpeg png pdf doc docx. Supporting Documents Files must be less than 5 MB.Allowed file types: jpg jpeg png pdf doc docx. Submit any additional supporting documentation by email to firstname.lastname@example.org or mail to: BYU Independent Study, Attn: Accommodations, 317 HCEB, Provo, UT 84602 Signature * By typing or signing my name below, I attest that all information on this form is accurate to the best of my knowledge.