Accommodation Request Form
DISABILITY SERVICES | 2020-2021
Welcome to Southwestern Michigan College! SMC is committed to comply with Section 504 of the
Rehabilitation Act of 1973, as amended, and with the Americans with Disabilities Act of 1990 (ADA) and to
provide accommodations to students with disabilities. SMC strives to provide equitable access to the
educational resources on our campuses and reasonable accommodations to achieve the goal of education
Students with a documented disability who want to speak with someone regarding strategies and
accommodations to remove disability related barriers should follow the steps below. Please note,
completing this form does not register a student with Disability Services or instate any accommodations
on its own. Please read the directions carefully and contact the Disability Services Coordinator with any
1. Turn in this completed form and documentation of disability to the Disability Services Coordinator in
the folder provided. The folder can be delivered to the Academic Advising and Resource Center (AARC)
on the first floor of the Briegel Building, on the Dowagiac campus. It may also be returned to the Student
Service Center on the Niles campus. Documentation Guidelines can be found in the
Policy and Procedure Guide. If this form is filled out from the online form, please submit the form and
documentation to firstname.lastname@example.org.
2. Once a folder has been turned in, an appointment must be scheduled. This can be done on location
when turning in a folder, by contacting the AARC at 269.782.1303, or via email.
Students without documentation are encouraged to consult their insurance provider to find
credentialed assessing facilities in their network.
Name: __________________________________________________ ID no. _____________________
City: ________________________________________ State: ________ Zip: ___________________
Phone Number: ______________________________ SMC email: ______________________________
Date of Birth: ___________________ Start Semester: _______________________________________
How were you referred to Disability Services?