Student Accommodations Request

Required

Studentrequired
First Name
Last Name
Student date of birthrequired
Must contain a date in M/D/YYYY format
Graduating yearrequired
Parent/Guardian or student filling out applicationrequired
First Name
Last Name
Relationship to studentrequired
Preferred emailrequired
Preferred phonerequired
Must contain only numbers
Student IDrequired

Diagnosis information

Is the student's diagnosisrequired
Please provide documentation of the student's diagnosis; neuropsychologist report, IEP, 504 plan or doctor's letter stating the diagnosis.required
Attach up to 5 files with a maximum size of 20MB
No file chosen
Disability falls into the following category(ies):required
If you selected "Other" above, please specify what type of diagnosis your student has.
Must contain only letters and spaces
Please describe what you understand about your diagnosis or your student's diagnosisrequired
Describe in detail how your diagnosis affects you, or your student, academically and in daily life. Give examples of limitations experiencedrequired
Describe the accommodations you are requesting and how they will alleviate your symptomsrequired

History of Accommodations

Have you used accommodations before?required
Month, date accommodations startedrequired
Month, date accommodations endedrequired
Month, date accommodations started (if needed)
Month, date accommodations ended (if needed)
Month, date accommodations started (if needed)
Month, date accommodations ended (if needed)
What types of accommodations have you received in the past and how significant were these accommodations in increasing academic success? required

RELEASE AUTHORIZATIONS 

EC Learning Support staff engages in an interactive and collaborative process with students and their families in order to determine eligibility for reasonable accommodations. Part of the process includes the submission and review of documentation related to the reported disability or limitations. At times, additional information may be requested. Documentation provided to the Learning Support staff is confidential and only shared with other offices or personnel at EC as necessary to put accommodations into effect. The identification of your disability is kept confidential, unless accommodations are approved and activated and then we will share the information with your teachers and counselors to best serve the student. Disability information may be released upon the student and guardian signing the Student Accommodation Plan.
I understand that any authorizations I make here may be withdrawn by student and guardian at any time through a written, signed and dated request.  
Parent/Guardian signaturerequired
Daterequired
Must contain a date in M/D/YYYY format