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Allegany College of Maryland - Request for Disability Accomodations

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1
__________________________________________________________________
Revised 7/27/18
ACM Academic Access & Disability Resources
Student Intake Packet
Demographic Data
Name: _____________________________________________________________________
Last First MI
Local Phone #: ______________________ Permanent Phone #: ____________________
Cell Phone #: ______________________ E-Mail: _______________________________
Student ID #: ______________________ Birth Date: _____________________________
Student Status and Background Information
□ I am returning to ACM
□ This is my first semester at ACM
Program of Study: __________________________________________________
Advisor: ____________________________________
□ I graduated from high school with Diploma (school/year):
□ I graduated with a GED (year): ____________________
□ I live independently
□ I live with parent or guardian (name(s)): ___________________________________
Referral Information: How did you hear about this office?
□ High School Counselor or Teacher
□ Friend or Family Member
□ Allegany College Staff of Faculty Person
□ Community Event/Organization _____________________________________
□
Other, please specify: __________________________________________________
____________________________________________________________________
____________________________________________________________
____________________________________________________________
Disability Information
1. For what diagnosed disability are you seeking disability accommodations?
(check all that apply)
□
Attention Deficit Disorder (Add)/
Attention Deficit Hyperactivity Disorder
(ADHD)
□
Blind/Visual Impairment
□
Deaf/Hard of Hearing
□
Health Impairment
□
Learning Disability (LD)
□
Mental Health/Psychological/Psychiatric
Impairment
□
Mobility/Physical Impairment
□
Speech Impairment
□
Traumatic Brain Injury
□
Other Impairment (please specify)
____________________________
2. When was this disability first identified or diagnosed?
3. Have you received disability accommodations for this disability in the past?
□ Yes □ No
If yes, where did you receive these accommodations? (check all that apply)
□ elementary school □ middle school
□ high school □ community college
□ another university/4-year college
4. Are you a client of a rehabilitation agency?
□ Blind Services □ Vocational Rehabilitation (ex. DORS)
□ Veterans Administration Vocational Rehabilitation (e.g. Chapter 31)
□ Other (please specify) ___________________________________________
□ None
5. Please list any medication(s) you currently are taking that may affect your
performance as a student and the side effects of those medication(s):
2
___________________________________________ __________________________
6. Please circle the two-letter code for the accommodations that you are requesting:
Classroom Accommodations:
□ FU Adaptive furniture or equipment
□ PP Access to visual aids/Power Points, when available
□ WR Additional time on in-class writing assignments
□ AL Assistive listening device
□ TP Audio taping lectures
□ CV Captioned videos
□ EX Brief exit classroom when symptoms occur
□ IN Interpreting/transcribing services
□ NT Note-taker (dedicated or volunteer)
□ AB Rare exceptions to absentee policy when it does not compromise course
objectives
□ SE Preferential Seating
□ LT Use of laptop computer for notes or in-class writing assignments
Testing Accommodations:
□ AT Assistive technology, such as reading and writing software
□ CA Calculator when it does not interfere with course objectives
□ CE Computer access for essay exams
□ ET Extended time on exams
□ DR Distraction reduced testing environment
□ LP Large print exams
□ SC No scantrons
□ RE Reader
□ SB Scribe
□ SC Spell check
Other Accommodations:
□ CM Classroom moved to accessible location
□ EL Electronic version or enlarged textbooks and course materials
□ CL Reduced course load (while maintaining full-time status)
□ OT Other
************************************************************************************************************************
I WILL NEED ASSISTANCE IN EMERGENCY EVACUATION SITUATIONS
□ YES □ NO
If you need assistance, this information will be shared with Campus Security.
I understand that arranging services will necessitate sharing with my instructors information regarding my
disability as it relates to my academic welfare. I give my permission for Disabilities Resource’s office
personnel to contact my instructors regarding my academic progress, as needed.
Signature Date
3
__________________________________ ________________________
Academic Access & Disability Resources Office
Ms. Dione Clark-Trub, Access and Resources Coordinator
Dr. June Bracken, Director
12401 Willowbrook Road, SE
Cumberland, Maryland 21502-2596
Email: adr@allegany.edu
301-784-5234
301-784-5090 (Fax)
Student Responsibility Sheet
You have the responsibility:
□ To inform the college of your needs. You must make the request every
□ semester.
□ To complete (with or without assistance) necessary registration forms to
□ request accommodations and support services as needed.
□ To provide the college with documentation of your disability in order to
□ receive accommodations.
□ To notify your instructors as to the accommodations you have been
□ approved to receive.
□ To give the Student Success Center at least 72 hours notice to receive
□ testing accommodations (reader, extended time, etc).
□ To keep arranged appointments with tutors/Disability Services
□ Personnel, note-takers, interpreters, etc.
□ To adhere to all college and disability services policies and procedures
□ regarding accommodations and service requests.
□ To strive to be as independent as possible.
□ To treat the program staff with courtesy and respect.
□ To take personal responsibility for your education by actively
□ participating in class activities.
□ To inform the program staff when you will no longer need a requested
□ accommodation.
□ To contact the program staff if instructors are not providing agreed upon
□ accommodations.
□ To report any grievance to program staff if you feel that your needs are not
□ being met.
By checking each statement and signing below, you are agreeing to carry out
your responsibilities.
Signature Date
4
_______________________________
_______________________________
_______________________________
____________________________________
____________________________________
_______________________________
_______________________________
_______________________________
_____________________
Academic Access & Disability Resources Office
12401 Willowbrook Road, SE
Cumberland, Maryland 21502-2596
301-784-5234
301-784-5090 (Fax)
Release of Information Form
(Optional)
Date: ______________________
I, _________________________________, give the Disability Resources Office,
(Student Name)
faculty, and staff permission to release any academic information regarding the
accommodations I receive and my performance at Allegany College of Maryland to the
following agency or persons indicated below:
Name (ex. Parent/Guardian or Agency)
Relationship
Phone number
This authorization is valid through:
□ Current Semester
□ Current Academic Year
□ Graduation
Student Signature*
Student’s ID Number
*Note: An original signature is required
Name (ex. Parent/Guardian or Agency)
Relationship
Phone number
Date
5
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Allegany College of Maryland - Request for Disability Accomodations

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Completed 29 April 2020

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