REQUEST FORM FOR DISABILITY ACCOMODATIONS

East Valley College would like to provide our students with disabilities the appropriate and reasonable accommodations they need to fulfill all requirements of their certification program. Please complete and submit the form below in order to begin the process for accommodation. If you have questions or need assistance completing this form, please contact Student Services at info@eastvalleycollege.com or 626-852-2000 Information contained on this form will be kept confidential and will only be revealed by CCC to those individuals who have a need to know (for example to assist in providing you with an accommodation) or if otherwise required by law. Your accommodation request will be reviewed only when the necessary medical documentation is submitted. Once you have finished filling out this form return it to Student Services. Please take a moment to view Policies and Procedures for Learners with Disabilities. The fields with an asterisk (*) are required.
First Name* ____________________________ Last Name* ____________________________
Student ID ____________________________ Enrollment Stage _______________________
Daytime Phone* _______________________ Evening Phone _________________________
Primary Email* _________________________ Alternate Email _________________________
Best Time To Contact ____________________ My Disability (diagnosis and description) * ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Describe in your own words limitations caused by the condition you have named. * ______________________________________________________________________________ ______________________________________________________________________________ Describe how an accommodation will enable you to be successful as a student. * ______________________________________________________________________________ ______________________________________________________________________________
Please indicate your current operating system software type (Mac/Windows/Linux/Other) and version, if known. _____________________________________________________________________________ ______________________________________________________________________________
Please list any and all assistive software (including version, if known), tools, and/or aids that you currently use as a result of your disability. ______________________________________________________________________________ ______________________________________________________________________________