Disability Accommodation Request Form by Yearoveryear


									                            Chemeketa Community College
                                 Disability Services

                        Accommodation Pre-application Form
Name______________________________ SSN/K#______________________________


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

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
                           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

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