To ensure the provision of reasonable and appropriate services and/or accomodations for students with medical disabilities at Randolph-Macon College, a physician who is qualified to diagnose the disability must provide current and comprehensive documentation of the student's medical disability.

Please complete the following for _______________________________________ who has requested disability-related services and accomodations from the College. (Please print or type).

1.       Medical diagnosis: __________________________________________________________________

2.       Date of diagnosis: __________________________________________________________________

3.       Date of your last contact with the student: ___________________________________________

4.       What procedures were used to diagnose the disorder?       ___________________________________
          _______________________________________________________________________________

5.       Please describe the presenting symptoms of the condition:       ___________________________
          _______________________________________________________________________________
          _______________________________________________________________________________
          _______________________________________________________________________________
          _______________________________________________________________________________

6.       Is the student currently taking medication for this condition? _______ Yes _______ No
          If yes, what is the medication?     ______________________________________________________

7.       Please describe the impact of this condition on the student's non-academic life (e.g. housing, physical
          facilities,) and on academic performance so that the College can determine the specific
          accommodations which may be necessary:          __________________________________________
          _______________________________________________________________________________
          _______________________________________________________________________________
          _______________________________________________________________________________
          _______________________________________________________________________________

Please attach any additional information that you believe to be relevant to the student's disability-
related academic needs.

Signature:     _________________________________________________________________________

Print Name and Title:     ________________________________________________________________

License #:     _________________________________________________________________________

Address:

Street: __________________________________________________________________

City: ___________________________________________________________________

State: ________________________________       Zip: ___________________________

Phone: __________________________________________

Date: ___________________________________________

Return this form by June 1^st to:

Randolph-Macon College
Office for Disability Support Services
Higgins Academic Center
P.O. Box 5005
Ashland, VA 23005

Phone: (804) 752-7343
Fax:     (804) 752-3744