LEARNER SELF-DISCLOSURE STATEMENT California Southern University recognizes and accepts its responsibilities under the Americans with Disabilities Act of 1990 (ADA) and the ADA Amendments Act of 2008, prohibiting discrimination on the basis of disability and requiring the University to provide reasonable accommodations to qualified disabled learners in all University programs and activities. The University Office of Compliance, in conjunction with the California Southern University Office of Disability Services, manages determination of reasonable accommodations and compliance with the ADA for learners. No learner shall be retaliated against for seeking accommodation under this policy or for participating in any complaint procedures brought against the University for its alleged non-compliance with the policy. Please complete this form and return it to the California Southern University Office of Disability Services. Attach any additional material(s), as necessary. 1. Please describe the nature of your disability.
2. Please describe any accommodations you have previously received in an educational environment.
3. What accommodations do you feel would be appropriate at California Southern University?
Learner Name
Learner Signature
Date
If signed by conservator, please attach the legal document appointing conservatorship of the learner. PLEASE RETURN TO: California Southern University Office of Disability Services California Southern University Attention: Disability Services 600 Anton Blvd Suite 1100 Costa Mesa, CA 92626 Tel: 714.882.7872 / 800.477.2254 ext. 4272 Email: disabilityservices@calsouthern.edu www.calsouthern.edu | 600 Anton Blvd Suite 1100 Costa Mesa, CA 92626 © 2022 California Southern University | Rev. 09.2019