Chemeketa Community College Disability Services Accommodation Pre-application Form Name______________________________ SSN/K#______________________________ Address_________________________________________________________________ City__________________________________State Zip Code Phone_____________________________ Email________________________________ Please indicate whether you are in or considering: 2 year, 1 year or certificate program GED Transferring to a 4 year school Unsure NATURE OF DISABILITY Indicate accommodations generally required to assist you in your educational/campus life experience. Attach additional pages to provide documentation of your disability, more details concerning your disability, and specific accommodations requested. Returning Student Requesting the same accommodations as last year with no changes. Specific Learning Disability____________________________________________ Accommodations requested: ____________________________________________ Sensory Disability_____________________________________________________ Accommodations requested: ____________________________________________ Psychiatric/Emotional Disability_________________________________________ Accommodations requested: ____________________________________________ Physical Disability_____________________________________________________ Accommodations requested: ______________________________________________ Student signature: _______________________________________________________ Initial one: ___Yes ___No I have read the “Documentation of Disability” brochure. Office use only: Date of appt.__________ Acc. Spec.__________ To request this form and the Disability Services brochure in an alternative format, call 503-399-5192. Chemeketa Community College Disability Services A student who requests reasonable accommodation related to a disability must provide information and recent documentation to Disability Services concerning his/ her specific disability or condition and the requested accommodation as specified by a physician or an appropriate professional. Chemeketa Community College wants to assist students with disabilities in realizing their personal educational goals by working for reasonable accommodations in the academic environment. You are encouraged to provide additional information regarding services you have found helpful in a previous educational setting. In order for us to schedule an appointment for you, we must have this completed form accompanied by your documentation. To request this form and the Disability Services brochure in an alternative format, call 503-399-5192.
Pages to are hidden for
"Disability Accommodation Request Form"Please download to view full document