Student Request for Accommodations

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I am requesting the following accommodations from CFCC Student Accessibility Services (SAS). I understand that accommodations are based on the functional limitations created by my disability as they impact the standards of the courses within the curriculum for which I am enrolled. I will provide, to SAS, the appropriate documentation that states my need and eligibility for the accommodations I am requesting.

Email *

Name *

Today's date *

YYYY

Phone number *

Student ID

*If you do not have a student ID yet please leave this question blank.

ACCOMMODATIONS REQUESTED: *

CURRENT IMPACT STATEMENT
Please indicate how your disability/condition impacts your functioning:
*

PERMISSION AND STATEMENT OF UNDERSTANDING

By checking the AGREE checkbox, I give SAS staff permission to share information with CFCC officials who have a legitimate educational interest. I also give permission to SAS staff to discuss the implementation of the accommodations with appropriate faculty/staff, if deemed necessary.

PERMISSION AND STATEMENT OF UNDERSTANDING
*

Agree

Disagree

Required

CONFIDENTIAL

The information is provided by the Student Accessibility Services office for the purpose of educational planning. We appreciate the respect for the student’s confidentiality and your understanding that state and federal laws prohibit the release of this information to any other person or agency or for use in any manner for any other purpose. Students with disabilities are eligible for appropriate services stipulated under Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. Student Accessibility Services has received all necessary documentation that substantiates the student’s need for academic accommodations.

A copy of your responses will be emailed to the address you provided.

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