Fillable Accommodation Request Form (Lakeshore Technical College)

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Accommodation Request Form (Lakeshore Technical College)

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___________________________________________________________ ______________________________
__________________________________ _______________________ ___________ __________________
________________________________ ________________________________ ________________________________
Accommodation Request Form
Contact Information Date: _________________________
First Name Middle Last Student ID
Street City State Zip Code
Phone Number Program E-mail address
Status
New Student Continuing Student I have not yet applied
I am Requesting Accommodation Service(s) to begin:
Fall 20___ Spring 20___ Summer 20___
Title IX Accommodation Request
Are you requesting accommodations based on pregnancy or parenting? Please check the box below, and
continue to the Student Release of Information section of this form. You will also need to have the Pregnancy &
Parenting Health-Related Documentation Form https://gotoltc.edu/Assets/gotoltc.edu/pdf/about-
us/Pregnancy%20Childbirth%20documentation.pdf completed by a qualified medical doctor or specialist.
Pregnancy and Parenting Accommodation(s)
ADA Accommodation Request (Documentation must support each requested service)
I am requesting the following classroom and campus access services:
Note-taking Services Enlarged Course Materials, font size: _____
Lecture Recording Braille course materials
Alternative Format (Audio) Textbooks Preferential Seating
Sign Language Interpreter Accessible Parking
Captioning
Accessible furniture – describe: __________________________________________________
Other (specify): _______________________________________________________________
I am requesting the following testing services:
Extended time (time-and-a-half) Enlarged Print, font size: _____
Separate Room (minimal distraction) Braille
Test Reader/Screen Reading Software Calculator
Test Scribe
Other (specify): ______________________________________________________________
Julie DeZeeuw, M.S. Ed. | 920.693.1222 | julie.dezeeuw@gotoltc.edu
Christi Leonhard, BSSW | 920.693.1274 | christi.leonhard@gotoltc.edu
Lakeshore Technical College | 1290 North Ave, Cleveland, WI 53015
05/2020 I:\AccommodationServices\Student Intake Forms 1 / 3
Accommodation Request Form
Personal Statement
In your own words, please describe your disability and why you need the accommodation services
that you are requesting.
Academic support services previously used:
Where were these services used? High School _____ College _____ Other: ________________
Documentation
In order to determine eligibility and to receive services, students must submit documentation. In
general, documentation should be from within five (5) years of the date of request for services.
An Individual Education Plan (IEP) from high school may be submitted for documentation, but will
not necessarily be sufficient documentation for determining eligibility, depending upon the IEP
content and identified disability.
Documentation must include:
• Test results, diagnosis and resulting limitations as determined by a qualified professional
• Limitations must significantly limit at least one major life activity in an educational
setting (mobility, vision, hearing, learning, etc.)
• Documentation guidelines can be found on our website: https://gotoltc.edu/current-
students/student-support-services/ada/index.html
Check one:
My documentation is enclosed
I plan to submit my documentation to Accommodation Services
I have previously submitted my documentation to Accommodation Services
If you have questions about documentation, please contact Julie DeZeeuw (920.693.1222) or
Christi Leonhard (920.693.1274) in Accommodation Services.
Julie DeZeeuw, M.S. Ed. | 920.693.1222 | julie.dezeeuw@gotoltc.edu
Christi Leonhard, BSSW | 920.693.1274 | christi.leonhard@gotoltc.edu
Lakeshore Technical College | 1290 North Ave, Cleveland, WI 53015
05/2020 I:\AccommodationServices\Student Intake Forms 2 / 3
Accommodation Request Form
Student Release of Information:
I hereby authorize release of information related to my accommodation plan to current
Lakeshore Technical College instructor(s), advisor(s), and appropriate staff for assisting the
College in the implementation of reasonable accommodation(s) for the courses, programs,
and/or activities in which I am enrolled. I understand that this information will be confidential
and only disclosed to those authorized by me or with legitimate educational interest in the
accommodation(s) requested. I also give my permission for information regarding my
accommodation plan to be shared with the individuals below. I understand that I can submit a
written statement revoking or changing this authorization at any time.
______________________________ ______________________________
______________________________ ______________________________
Submission of this request does not imply you will receive services. In addition to this application, in order to be
eligible for disability related accommodations, students must have a documented disabling condition as defined by
the Americans with Disabilities Act of 1990 (ADA), ADA Amendments Act 2009 and Section 504 of the Rehabilitation
Act of 1973.
Student Signature: ___________________________________________ Date: ______________
Please complete and return this form to Accommodation Services:
Email: julie.dezeeuw@gotoltc.edu
Fax: (920) 693-1827
Mail: 1290 North Ave, Cleveland, WI 53015
Accommodation Services Office Use Only:
Request(s) Approved: communication with student on: ________________________
Request(s) Denied: communication with student on: __________________________
Julie DeZeeuw, M.S. Ed. | 920.693.1222 | julie.dezeeuw@gotoltc.edu
Christi Leonhard, BSSW | 920.693.1274 | christi.leonhard@gotoltc.edu
Lakeshore Technical College | 1290 North Ave, Cleveland, WI 53015
05/2020 I:\AccommodationServices\Student Intake Forms 3 / 3
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Accommodation Request Form (Lakeshore Technical College)

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Completed 27 July 2020

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