ACCOMMODATION REQUEST FORM

Alamance Community College provides appropriate accommodations to meet the needs of any enrolled student with a physical, emotional, or learning disability. By completing this form, you are identifying yourself as having a disability. The information you provide is voluntary and will be shared only with personnel responsible for meeting your needs. If you require services, please complete this form and return to:

Monica Isbell, Coordinator of Special Needs & Counseling Services

Alamance Community College

PO Box 8000

Graham, NC 27253

FAX: (336) 506-4264

E-mail:

Student’s Name: ______SSN or Student ID Number: ______

Semester for which you are requesting accommodations: ______

Address: ______

______Phone: ( ) ______

Other contact information (cell phone number, email address): ______

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

____ ADD/ADHD ____ Autism/Asperger’s Syndrome

____ Blind/ Low Vision ____ Deaf/Hard of Hearing

____ Intellectual Disability ____ Learning Disability

____ Mobility ____ Physical

____ Psychiatric ____ Speech/Language

____ Traumatic Brain Injury ____ Other ______

Please address ALL three (3) of the following questions in as much detail as possible. Feel free to use the back of this form, or type your response on additional paper. Incomplete responses will be returned for more information.

1.  Considering the skills such as reading, writing, paying attention, mathematics, etc., describe ( be specific) the current (or recent) impact of the disability/medical condition in both of the following areas:

a.  In Class (lectures, test-taking, participation, etc.)

______

b.  Out of Class (studying, time management, homework, etc.)

______

2.  What accommodations/ services have you used in the past?

______

3.  Describe the accommodations or services that you think you will need at ACC. Why?

______

In addition to your response, you may also ask others who currently know you, or have observed you to submit answers to these questions in a separate document.

Before accommodations can be implemented you must provide appropriate documentation of your disability/medical condition and meet with the Coordinator of Special Needs to discuss the request.

Student’s Signature: ______Date:______

Documentation Guidelines: Documentation is necessary because a professional assessment is the basis for determining reasonable services and accommodations. Documentation guidelines are located on the Disability Services Moodle site at www.alamancecc.edu. To access the Moodle site, select “Services for Students”. There is drop down menu to select “Disability Services” and follow the directions.

Staff Documentation Do not write in this section

Documentation Received: ______

Accommodations Approved: ______Denied: ______Adjusted: ______Declined: ______

Accommodation letter given: ______

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4-8-2015