Pregnancy Adjustment Request for Southwest Tech students

Pregnancy Adjustment Request

Please use this form to submit a pregnancy adjustment request. This submission will route directly to our Staff and be time stamped upon submission.

We will contact you directly within 5 business days.

Fields marked with an asterisk * are required.

Student Information

The information below pertains to the student requesting or need of support from the Office of Disability Services.

Student Name

* First Name:

* Last Name:

Charger ID#:

* Email Address

* Phone Number:

* May we leave a message?

You Must Choose Yes or No.

Intake Questions

* Select the term(s) for which you are requesting assistance:

Please Choose At Least One Term

Expected due date if applicable: (mm/dd/yyyy)

Supporting Documentation

* How will you provide pregnancy-related documentation that supports your request?

Please Choose A Delivery Option

Upload electronically (see below)
Mail to Disability Services, Southwest Tech, 1800 Bronson Boulevard, Fennimore, WI 53809
Email (provided in confirmation email)
Fax to 608-822-2673

Required

* Disability Services has my permission to collaborate with SWTC staff and faculty for educational purposes.

You Must Choose Yes or No.

*The undersigned agrees to conduct this transaction electronically. The undersigned understands that their consent to conduct this electronically is not consent to conduct any future transaction electronically.

Pregnancy Adjustment Request

Uploaded Documents