STUDENT ACCOMMODATION REQUEST FORM

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Student Accommodation Request Form

Accessibility Services

Alamance Community College

PO Box 8000

Graham, NC 27253

E-mail: accessibilityservices@alamancecc.edu

Fax: (336) 506- 4353

First Name

Last Name

Middle Name

Are you registering for accommodations for placement testing? (GED/ High school equivalency, ABE/ABLE, etc.)

Semester(s) for which you are requesting accommodations:

Address

Phone Number

ACC Email Address

Please use your ACC issued email address

Specific Accommodation Information

Please address the following questions in as much detail as possible.

What is your disability?

(Do the best that you can to explain this)

Is this a temporary impairment or on-going condition? If a temporary impairment, what is the anticipated duration?

Please describe how your disability impacts major life activities.

(examples: caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, speaking, breathing, learning, reading, concentrating, thinking, communicating or major bodily function, etc.)

If applicable, describe any supports, modifications, or accommodations previously used and where:

What accommodations are you requesting?

Are there any other resources/supports you need? If there is anything else you would like to share, please enter that here.

Upload supporting document(s)

You may submit documentation one of two ways: please either submit documentation now electronically by uploading files (preferred method) or submit in-person by mail or fax using the address or fax number listed at the top of this form. Thank you!

Student's Signature:

STUDENT ACCOMMODATION REQUEST FORM

Student Accommodation Request Form

Specific Accommodation Information

Document Information