Application for Accessibility Services
Email address *
I check my e-mail regularly. *
Full name *
Your answer
Student ID number *
Your answer
Address *
Your answer
Date of birth *
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Cell phone
Your answer
Home phone
Your answer
My home phone is
Work phone
Your answer
What is the best way to contact you? *
Required
I have *
Date of completion *
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Name of high school, if applicable.
Your answer
When will accessibility services need to begin? (Fall, Spring, or Summer 20xx) *
Your answer
Campus Location *
Financial/Program Assistance
If Rehabilitation Services checked above, enter counselor(s) name(s).
Your answer
Disability (please check all that apply) Documentation of disability must be provided. *
Required
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.)
Required
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.)
Required
How did you learn about our services? *
Required
For questions about this form, please contact Accessibility Services Coordinator, Lisa Jolliff at jolliffl@hutchcc.edu or 620-665-3554
Documentation of disability is required. 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 Accessibility Services Coordinator 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. *
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): Coordinator of Equity & Compliance, 1300 N Plum Hutchinson, KS 67501, 620-665-3500, equity@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. *
Today's date *
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