Application for Accessibility Services
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Email *
I check my e-mail regularly. *
Full name (First name, Middle Initial, Last name) *
HutchCC Student ID number *
Street address   *
City, State and Zip Code *
Date of birth *
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Cell phone
Home phone
My home phone is
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Work phone
What is the best way to contact you? *
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I have *
Date of completion (Month/Year) *
Name of high school, if applicable.
When will accessibility services need to begin? *
Do you need accommodations for Accuplacer placement testing?
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Campus Location *
Financial/Program Assistance
If Rehabilitation Services checked above, enter counselor(s) name(s).  
Disability (please check all that apply)      Documentation of disability must be provided. *
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Accommodations-Instructional *
Based on your disability, check the accommodation(s) you will need in college in order to have equal access.  (Accommodation approval is based on supporting documentation of disability.)
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Accommodations-Testing *
Based on your disability, check the accommodation(s) you will need in college in order to have equal access.  (Accommodation approval is based on supporting documentation of disability.)
Required
Accommodations-Support Persons *
Based on your disability, check the accommodation(s) you will need in college in order to have equal access.  (Accommodation approval is based on supporting documentation of disability.)
Required
Accommodations-Environment *
Based on your disability, check the accommodation(s) you will need in college in order to have equal access.  (Accommodation approval is based on supporting documentation of disability.)
Required
Accommodations-Equipment *
Based on your disability, check the accommodation(s) you will need in college in order to have equal access.  (Accommodation approval is based on supporting documentation of disability.)
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Please provide additional information about how your disability affects your learning and what  accommodations you feel you need in order  to have equal access at Hutchinson Community College. 
How did you learn about our services? *
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For questions about this form, please contact the Director of Accessibility Services, Lisa Jolliff at jolliffl@hutchcc.edu or 620-665-3554 *
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Documentation of disability is required. Please email documentation to accessibilityservices@hutchcc.edu. In order to ensure that accommodations are provided in a timely manner, appropriate documentation of disability should be submitted six weeks in advance of receiving the approved accommodations.  Once documentation is received and approved, you will need to meet with an Accessibility Services staff member to discuss accommodations, procedures, and policies.  Information regarding disability is kept in the office of the Director of Accessibility Services and is not part of the student's permanent record.  All documentation received by HutchCC Accessibility Services Office will be stored in accordance with all state and federal laws. *
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Hutchinson Community College does not discriminate on the basis of race, color, national origin, sex, disability, religion, age, military status, sexual orientation, or any other protected category under federal, state, or local law, or by college policy.  The following person has been designated to monitor compliance and handle inquires regarding the non-discrimination policies (www.hutchcc.edu/equity):  Title IX and Title VI Coordinator, 1300 N Plum Hutchinson, KS 67501, 620-665-3512, dillonb@hutchcc.edu. To learn more about the Notice of Nondiscrimination, visit the Department of Education's Office for Civil Rights website (https://wdcrobcolp01.ed.gov/CFAPPS/OCR/contactus.cfm) for the address and phone number of the office that serves your area, or call 1-800-421-3481. *
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Today's date *
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