Viterbo University - The University of Opportunity: Hope and Help

Disability Services


Application for Services: Federal Law prohibits Viterbo University from making pre-admission inquiries about disabilities. To provide assistance it is prudent for students with disabilities to identify themselves in a timely manner. Information you provide is voluntary and is kept confidential. To facilitate your learning experience at Viterbo University, complete the following information and submit this form along with proper disability documentation to Jane Eddy, disability services coordinator at 608-796-3194 or

First name    Last name  
Address   City   State     Zip   
Student cell phone     Student email  
Date of birth    Gender     Ethnicity  
Program of study (intended academic major)  
Do you have a disability that limits one or more major life activities?

What is the nature of the disability? (Check all that apply)


If other, specify  


What major life activity is involved? (Check all that apply)


If other, specify  


How does this disability affect you in an educational setting?

Read and sign below:

  • It is the student’s responsibility to make a disability known and to provide proper documentation (including test results) from a licensed professional describing diagnosis, limitations, and recommended academic adjustments and/or auxiliary aids. Documentation should not be more than two years old.
  • It is the student’s responsibility to request services in advance each semester.
  • The student understands that academic adjustments and/or auxiliary aids are not automatically granted.

My signature below certifies that the information provided is accurate and acknowledges that I am fully aware of my responsibilities as it relates to my request for services. Failure to follow these guidelines may result in a delay or interruption of services.