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
for all.
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
questions.
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
Disability Services
Policy and Procedure Guide. If this form is filled out from the online form, please submit the form and
documentation to disabilityservices@swmich.edu.
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.
Student Information
Name: __________________________________________________ ID no. _____________________
Address: ____________________________________________________________________________
City: ________________________________________ State: ________ Zip: ___________________
Phone Number: ______________________________ SMC email: ______________________________
Major: _______________________________________________________________________________
Date of Birth: ___________________ Start Semester: _______________________________________
How were you referred to Disability Services?
Is this a temporary or permanent condition?
What is your diagnosis?
Accommodation Request
What accommodations are your requesting?
ADDITIONAL TIME FOR TESTING
TESTING IN THE TESTING CENTER
TESTING IN A PRIVATE ROOM
SCREEN READER
SCRIBE SERVICES
SERVICE OR ASSISTANCE ANIMAL IN HOUSING
ASSISTIVE TECHNOLOGY: FM SYSTEM
BOOKS IN ADAPTED FORMAT
POWERPOINT COPIES
ENLARGED HANDOUTS
DIGITAL RECORDING
NOTETAKING SERVICES
SEATING CONSIDERATIONS
ATTENDANCE CONSIDERATIONS
PREFERENTIAL REGISTRATION
SIGNED LANGUAGE INTERPRETER
Other Accommodations:
Are you requesting any other accommodations not listed above or would you like to clarify a request?
Confidentiality
Information regarding the nature of a student’s disability and request for accommodations provided to
Disability Services will remain confidential. Disability information will not be shared with any other entity
or individual unless there is a genuine academic need, or the student has provided written consent in
accordance with the Family Educational Rights and Privacy Act (FERPA). Disclosure of specific information
about a student’s condition(s) may be necessary to ensure the proper implementation of an
accommodation. In such an event the student and Disability Services Coordinator will determine together
what information will be shared and the student will give written consent via the Consent to Share
Information form.
I certify that all information supplied to this document is accurate to the best of my knowledge. I give
permission for the Disability Services Coordinator to have access to my enrollment and grade information.
Student Signature: ___________________________________________ Date: ___________________
Please attach documentation or add it to the folder provided (IEP, 504, Clinician Form or other
assessments from a qualified evaluator, professional, or institution), and submit to the Disability Services
Coordinator:
ACADEMIC ADVISING AND RESOURCE CENTER | BRIEGEL BUILDING
58900 CHERRY GROVE RD| DOWAGIAC, MI 49047
disabilityservices@swmich.edu
| p: 269.782.1303 | f: 269.782.1331
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