Fillable Access Application (Eastern Florida State College)

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Access Application (Eastern Florida State College)

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U.S.A. forms for Eastern Florida State College

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Student Accessibility Application
Student Access for Improved Learning (SAIL)
Today’s Date: ______________________________ B#: ________________________________
Name: _______________________________________________ DOB: ________________________________
Address: _______________________________________________________________________________________________
Street City State Zip Code
Phone #: ________________________________ Alternate Phone #: ___________________________________
EFSC Titan email: ___________________________________ Alternate Email: _________________________________
EFSC requires that all official email communication occur through your EFSC Titan email, which you
can access through myEFSC. If you do not have an EFSC email yet, SAIL staff will use your alternate
email until you sign up for your EFSC Titan email.
Disabil
ity Information:
Physical or Mobility
Specific Learning Disability
Blind or Low Vision
Psychological or Mental Health
Deaf or H
ard of Hearing
Autism Spectrum Disorder
Speech
Medical
Other: ______________________________________________________________________________________________
Temporary Disability: ______________________________________________________________________________
When do you expect to return to your regular state of functioning? _____________________________
Describe how your major life activities are substantially limited by your disability.
Describe how your disability impacts your academic performance.
What accommodations have been effective for you in the past?
List a
ny medication(s) that may have side effects or may impact your academic performance:
Additional Comments:
Academic Information:
(Select One) Are you:
First-time college stud
ent
P
rospective student
Transfer student
Transient student ________________________
name of college/university
Main Campus:
Melbourne
Cocoa
Palm Bay
Titusville
eLearning
P
rogram: ________________________________________________________________
Have you attempted any course(s) 2 or more times? If so, please list: ___________________________
_________________________________________________________________________________________________________
________________________________________________________________________________________
_________________
Student Responsibilities: (P
lease initial each)
As a student requesting accommodations, I understand that I have the following responsibilities:
_______ I understand that I must provide appropriate documentation regarding my disability in
order to receive reasonable accommodations.
_______ I understand that I am responsible for communicating any questions or concerns that may
impact my disability accommodations.
_______ I understand that I must request to have Teacher Notifications sent each semester.
_______ I understand that I must self-disclose and have a discussion with my instructors before I will
receive accommodations.
_______ I understand that I am responsible for following the course syllabus and attendance policy
for each course.
_______ I understand that I must meet and abide by EFSC’s academic, conduct, and technical
standards.
Eastern Florida State College is not obligated to honor disability accommodations from
previous institutions.
Academic requirements that are essential to the program of instruction being pursued by the student or to any
directly related licensing or certification requirement will not be modified, substituted, or waived.
The Student Access for Improved Learning (SAIL) office determines accommodations and
services based on documentation submitted by the student and the application review process.
Please allow at least 2 weeks for your application to be reviewed and processed. Applications
submitted within 3 weeks of final exams week will be processed for the following semester.
__________________________
_____________________________ __________________________________
Student’s Signature Date
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Access Application (Eastern Florida State College)

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Completed 25 July 2020

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