| Accessibility Services Office | ||||||
| Adirondack Community College | ||||||
| 640 Bay Road Queensbury, NY 12804 | ||||||
| Phone: 743-2282 TTY: 743-2323 | ||||||
| Fax 743-2241 | ||||||
| Release and Collection of Disability Related Information | ||||||
| Collection Statement | Under Section 504 of the rehabilitation Act of 1973, a post-secondary student with a disability is required to provide appropriate documentation, which supports a request for reasonable accommodations or auxiliary aids or the qualifications necessary to participate in academic programs or courses. | |||||
| In recognition of this requirement I, _____________________________, give permission to the Accessibility Services Office to verify with the sources listed below that I am seeking accommodation based on a disability and to request supporting information and documentation of my disability status as necessary. I understand that all documentation is maintained as confidential as outlined in the Students with Disabilities Handbook. | ||||||
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~High School Guidance Office ~High School Psychologist ~Office of Vocational & Educational Services for Individuals with Disabilities (VESID) ~Commission for the Blind and Visually Handicapped (CBVH) ~Employment and Training Office ~Veterans Administration ~ACC Registrar ~ACC Counselors ~ACC Financial Aid Office ~ACC Business Office ~ACC Enrollment Management Office (Admissions) ~Bookstore ~Other________________________________________________________________________________ |
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| Release Statement | ||||||
| I understand that the Director of Accessibility Services and/or the Learning Specialist are legally allowed to consult with college faculty or staff that has legitimate educational interest in understanding the functional limitations presented to me by my disability. I understand that the sharing of information is limited to the purpose of assisting me to achieve my educational goals and to assure the effective implementation of assigned accommodations. I also understand that information related to my disability may be shared in the event of an investigation of a discrimination complaint, medical emergency or potential situations of harm to my self or others. College staff that may be consulted with regarding my disability includes, but is not limited to those identified below: | ||||||
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~ACC Counselors and/or Academic Advisor ~ACC Human Resource Development or College Survival Instructors ~ Director of Student Computing (assist in the coordination of technological accommodations) ~ ACC faculty as assigned ~Other:_____________________________________ |
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