Public Accommodation Request

Student Information

Please complete the following form to the best of your ability in order to request and establish accommodations at Carroll – upon completion of this form and following review of any supporting documentation you have provided, ADA Office staff will contact you by email for next steps.

Please remember this form is more of a “snapshot”/overview of your essential information and needs.

It is important that students also review the accompanying "Student Responsibility Agreement”, which outlines Carroll’s process and requirements for students to request and receive their accommodations for each semester. As always, please contact the ADA Office with any questions or for further clarification. We are here to help both now and along the way - thank you!

First Name

Last Name

Middle Name

Carroll Student ID

Carroll Student Email

Note – the ADA Office will primarily use your Carroll STUDENT email for all important communication, accommodation requests, etc.

Phone Number

Emergency Contact Name:

Emergency Contact Telephone #:

It is important to please notify both the College and ADA Office if you change any contact information.

Disability Information

What is your PRIMARY documented disability?

Approximately how old were you when your disability was diagnosed?

Please describe in your own words how the disability impacts you (in particular, how does it impact your learning?)

For example: “I get anxious/distracted during tests so it takes me longer…I have trouble listening to a lecture and taking notes at the same time…etc.

Secondary disability info – or any other related information that you feel is important to share?

(Secondary health conditions, allergies, migraines, etc.)

Education Information

High School

Graduation Year

Have you attended any other colleges/postsecondary institutions? (check one)

Accommodations:

Have you used any disability accommodations in the past four years? (check one)

What services or accommodations are you seeking at Carroll Community College?

Notes: we strive to honor student requests and meet all student needs, but accommodations should be reasonable and appropriate to the postsecondary/college environment. Accommodations do not necessarily guarantee success, but are intended to improve accessibility and to help you by offsetting the specific impact of a disability/health condition - when used in conjunction with other campus resources (such as tutoring), they can make a big difference.

By law, accommodations cannot fundamentally alter or compromise the academic standards of any assignment, course, program, or activity. Finally, please do not be concerned that you might neglect to request something right now – we understand student needs do evolve over time, and in different courses, so if you should suddenly discover that you need an additional accommodation at a future date, we are always open to revisiting, discussing and, when appropriate, adding or adjusting an accommodation as may be needed.

Agency Affiliations

Are you working with any other agency for academic, personal, rehabilitation or counseling? (DORS, VA, BERC, etc.) (check one)

Upload supporting document(s)

Types of supporting documentation

Psyc Eval
IEP
504 Plan
Medical Info
PCP (primary care physician) Letter

Signature

Please read the following, sign: Accommodations will be discussed and decided upon by you and the Office of ADA Support Services. When necessary, the Office of ADA Support Services may advocate on your behalf. I have reviewed and confirm I understand the list of Student Responsibilities for use of accommodations:

Office of ADA Support Services has my permission to discuss my accommodations (not personal health information) with my Instructors, Testing Center, agencies or care provider, and/or academic departments as may be needed for the purpose of coordinating accommodations, or to advocate on my behalf as may be necessary. I understand that all submitted documentation becomes the property of Carroll Community College and will not be copied, forwarded or returned (although ADA Office staff can make exceptions to assist students transferring to other institutions).