Accessibility Services Office
Adirondack Community College
640 Bay Road Queensbury, NY 12804
Phone: 743-2282 TTY: 743-2323
Fax 743-2241

The Office of Accessibility Services at Adirondack Community College provides students with disabilities with assistance and access to campus facilities and academic programs in accordance with the Americans with Disabilities Act of 1990 and section 504 of the Rehabilitation Act of 1973. If you feel that you are eligible for services under one or both of these provisions, please complete this form and the attached release form and return it to the Office of Accessibility Service at the address above.
Name:___________________________________________________   Date:_______________________________
Address:______________________________________________________________________________________
City:_______________________________________________ State:________________ Zip:__________________
Home Phone:__________________________________ Alternate/Cell Phone:_______________________________
E-Mail Address:________________________________________________________________________________
Date of Birth:________________________________ Social Security Number:_______________________________
Intended Major at ACC:__________________________________________________________________________
Enrollment Date: Fall   Spring   Summer 20____     Status: Full Time   Part Time
Agency Referral: (Check if Applicable) ETA   VESID   CBVH   VA
Other_________________________________   County___________________________
High School Attended:_____________________________________   Completion Date:________________________
DISABILITY INFORMATION
I have been identified as having the following Primary disability:
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I have been identified as having the following secondary disability:
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Your age at the time of the onset of your disability:__________
If applicable, please describe the cause of your disability:
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In your own words, please describe how your disability impacts your daily life activities:
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In your own words, please describe how your disability impacts your education or academic performance:
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What strategies do you use to compensate for the limitations your disability places on your academic pursuits?
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Please describe your academic strengths:
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Please describe your academic weaknesses:
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EDUCATIONAL ACCOMMODATION INFORMATION
If applicable, please list all academic accommodations and services you received in high school (extended test time, use of a calculator etc.) Please remember, accommodations at the college level may not be the same.
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Have you used books on tape from either RFB&D or a state organization?   YES____   NO____    If yes, do you plan on continuing to use this service while at ACC?   YES____   NO____    Do you have an individual membership with RFB&D?   YES____   NO____    Do you have a special format (4 track) tape player?   YES____   NO____ If no, are you interested in using this service if applicable to your disability?   YES____   NO____ Have you had books scanned and read via a Kurzweil Reader?   YES____   NO____    Are you interested in using this service if applicable to your disability?   YES____   NO____ Do you own a computer?   YES____   NO____    If yes, does your computer have any adaptive hardware?   YES____   NO____     ____Large Monitor (Size)?____   ____Mouse Alternative     ____Adapted Keyboard   ____Other Please list specific type:____________________________________________________________________    If yes, does your computer have any adaptive software?   YES____   NO____     ____Voice Recognition Software (e.g. Dragon)   ____Screen Reader (e.g. Jaws)     ____Screen Enlargement(e.g.ZoomText)   ____LD Software (e.g. WYNN, Kurzweil)     ____Other:____________________________________________________________________________     Please list specific programs_____________________________________________________________
SECTION V MEDICAL INFORMATION
Are you taking any prescribed medications (disability related)?   YES____   NO____ If yes, please specify: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________ Are you currently under a doctor.s care relating to your disability?   YES____   NO____ If yes, please explain: _______________________________________________________________________________________ _______________________________________________________________________________________ _______________________________________________________________________________________
PERSONAL EQUIPMENT
All students are responsible for the care and maintenance of their own equipment and the College does not keep extra equipment on hand. The following information is needed to help us prepare for emergency evacuations and crisis situations only.
Do you use: ____A motorized wheelchair   YES____   NO____   ____Backup Chair   YES____   NO____ ____A manual wheelchair   YES____   NO____   ____Backup Chair   YES____   NO____ ____A Scooter   YES____   NO____   ____Backup Chair   YES____   NO____ ____A cane (for physical)   YES____   NO____   ____A cane (for visual)   YES____   NO____ ____Crutches   YES____   NO____ ____A walker   YES____   NO____
If you have a visual or mobility impairment, will you require orientation/mobility Training when you arrive on campus?
YES____   NO____   UNSURE____
Explain:____________________________________________________________________________________
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COMMUNICATION
If applicable, please rate the level of your speech difficulty:   ____Mild   ____Moderate   ____Severe   ____Not able to speak
Do you use a speech communication device?   YES____   NO____
Please describe:____________________________________________________________________________
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Other Information that is important for us to know:
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ACCOMMODATIONS
Based on the information above, please indicate the accommodation/s you are requesting: (Please see the Accessibility Services Student Handbook for clarification on the definitions and process of obtaining accommodations)
Accessible Parking   Counseling   Interpreter Testing Accommodations   Special Scheduling   Reader Accommodative Seating   Note Takers   Tape Recorded Lectures Books on Tape Other_________________________________________________________________ Unsure
Please return this form with supportive documentation, and schedule an appointment with the Accessibility Services Director.
Signature____________________________________________      Date__________________