STUDENT ACCOMMODATION REQUEST FORM

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Student Accommodation Request Form

Disability Services

Alamance Community College

PO Box 8000

Graham, NC 27253

FAX: (336) 506-4353

E-mail: disabilityservices@alamancecc.edu

First Name

Last Name

Middle Name

Student ID

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?

What major life activity does your disability impact?

(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.)

How does your disability impact and functionally limit the major life activity or bodily function?

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

What accommodations are you requesting?

Why do you feel you need these?

What other resources/supports do you need?

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