Student Registration and Release Form

Accessibility Services Office
Adirondack Community College
640 Bay Road Queensbury, NY 12804
Phone: 743-2282
TTY/VP: (518)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. If you feel that you are eligible for services you must obtain supporting documentation, complete this form, and submit both items to the Office of Accessibility Service at the address above. Please contact the main office with any questions or concerns.

Name:___________________________________________________ Date:_______________________________

Address:______________________________________________________________________________________

City:_______________________________________________ State:________________ Zip:__________________

Home Phone:__________________________________ Alternate/Cell Phone:_______________________________

E-Mail Address:________________________________________________________________________________

Date of Birth:________________________________

Banner ID # _________________________ AND Social Security Number:_______________________________

Enrollment Date: Fall Spring Summer 20____

Status: Full Time Part Time

Agency Referral: (Check if Applicable) ETA VESID CBVH VA

Other_________________________________ Counselor's Name___________________________

DISABILITY INFORMATION

Please list the disabling condition/s for which you have been diagnosed:

_______________________________________________________________________________________

In your own words, please describe how your disability impacts your daily life:

_______________________________________________________________________________________

In your own words, please describe how your disability impacts your academic performance:

_______________________________________________________________________________________

What strategies or academic modifications do you use to compensate for the limitations your disability places on your academic pursuits?

_______________________________________________________________________________________

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:
_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

ACCOMMODATION INFORMATION

If applicable, please list all academic accommodations and services you were eligible for in high school (extended test time, use of a calculator etc.) Please remember, accommodations at the college level may not be the same.

_______________________________________________________________________________________

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 in Alternative Format	Unsure	Other
__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

I herby verify the above information is true and accurate to the best of my knowledge, and I acknowledge that I have received, read, and understand the Accessibility Services Student Handbook which outlines my rights and responsibilities as a student with a disability at Adirondack Community College.

Signature____________________________________________

Date__________________

Please return this form with supportive documentation to the Accessibility Services Office.

Accessibility Services Office

Adirondack Community College

640 Bay Road Queensbury, NY 12804

Phone: 743-2282

TTY/VP: (518)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.

~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________________________________________________________________________________

_______________________________________		_______________
Student Signature		Date

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:

~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:_____________________________________

_______________________________________		_______________
Student Signature		Date