If you would like to request this form in an alternative format please contact Disability Support Services at
301-934-7614 or via email at ADA@csmd.edu
COLLEGE OF SOUTHERN MARYLAND
SUMMER CAMP/KIDS COLLEGE REQUEST FOR
ACCOMMODATIONS
The Summer Camp/Kids’ College will comply with the Americans with Disabilities Act/ADAA and
all applicable federal, state, or local laws in providing services to individuals with disabilities. Our
goal is to
meet the individual needs of the child within the structure of our program.
“No otherwise qualified individual with a disability shall, solely by reason of his disability, be excluded
from the participation in, be denied benefits of, or be subjected to discrimination under any program
or activity receiving Federal financial assistance.” - Section 504 of the Rehabilitation Act of 1973
General Information:
Name: _______________________________________Today’s Date: ________________________
Name of
Parent/Guardian:
__________________________
__________________________
Date of
Birth:
______
_______
Studen
t ID Number:
___________
_
SSN: ___________
_________
Primar
y Phone:
_________
________________
Secondar
y Phone:
___________
______________
Street Address: ___________________________________________________________________
City: ___________
____
County: ________________ State: ________ Zip Code: ____________
Email:
_______________________________________________________________
ADA Accommodations Plan for Summer/Teen Camp
Disabilities: _______________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Discussion of Accommodation Requests For DSS ONLY:
A meeting was held on _______________ to discuss the accommodations
request. Documentation was appropriate
Documentation was inappropriate because: ______________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
If you would like to request this form in an alternative format please contact Disability Support Services at
301-934-7614 or via email at ADA@csmd.edu
Accommodation(s) recommended and agreed upon by the individual were:
__________________________________________________________________________________________
__________________________________________________________________________________________
Meeting attended by:
___________________________________,___________________________________,
___________________________________
Appropriate Accommodations
Accommodations/modifications agreed to:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Campus Attending: La Plata Leonardtown Prince Frederick
Hughesville
Waldorf
Other:
____________________
Parent/Guardian Signature:
___________________ Date: _______________________
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If you would like to request this form in an alternative format please contact Disability Support Services at
301-934-7614 or via email at ADA@csmd.edu
College of Southern Maryland Emergency
Guidelines for Ind
ividuals with Disabilities
The safety of individuals with disabilities is a shared responsibility. CSM is committed to developing
and implementing procedures to assist individuals with disabilities during an emergency. Likewise,
individuals with disabilities should create a personal emergency plan which addresses their needs
before and during an evacuation.
Development of a Personal Emergency Plan
The development of a personal emergency plan should include the following steps:
Step 1: Register
Students with disabilities who need assistance should register with the Disability Support
Services (DSS) office on the campus they are attending.
Step 2: Develop Personal Evacuation Instructions
Assistance required during an evacuation should be written down on a card and carried by the
individual with disabilities at all times. The card should instruct others on the best ways to
assist and the number of persons needed to help.
Step 3: Develop a “buddy system”
Prepare for emergencies in advance by establishing a primary and an alternate “buddy” for
each class or office location. A “buddy” could be a classmate, instructor, supervisor, or co-
worker. An individual’s personal evacuation instructions should be shared with their “buddies.”
A “Buddy” will assist individuals with disabilities to an evacuation assembly area outside the
building or to a safer area within a building (e.g. stair landing, room away from imminent
danger, another wing, opposite end of corridor). A second person should immediately notify
emergency personnel where an individual is located. Police or Fire/Rescue personnel will decide
if individuals are safe where they are or evacuate them as necessary. A “buddy” should stay
with an individual until the emergency is over.
If an individual with a disability is alone during an emergency, they should contact the campus
security office and provide their present location. The security office can be contacted by a cell
phone, a campus emergency telephone, or an office telephone.
Step 4: Know Your Environment
Become familiar with emergency exits, evacuation routes in campus buildings, and campus
evacuation assembly areas. Elevators are not to be used as an emergency exit unless
instructed by emergency personnel. Determine the building exit nearest your classroom or
office. In the event that this exit is blocked, be familiar with alternate exits.
Step 5: Know Campus Telephone Numbers
Campus Safety and Security
La Plata: 301-934-7888
Leonardtown: 240-725-5333
Prince Frederick: 443-550-6033
Disability Support Services for Students
La Plata: 301-934-7614
Leonardtown: 240-725-5420
Prince Frederick: 443-550-6009
Step 6: Register with Campus Facilities
It is important for campus facilities to maintain a list of individuals with disabilities who may
need assistance in case of an emergency. By registering, you may enable a more efficient
response in the future. You can register by completing the attached form and return it to your
campus’s ADA coordinator.
If you would like to request this form in an alternative format please contact Disability Support Services at
301-934-7614 or via email at ADA@csmd.edu
Campus Emergency Response Registration for Individuals with Disabilities
Student Name _______________________________ Date ______________________
Dis
ability ________________________________________________________
Special Needs in case of campus emergency:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Additional relevant info (i.e. “I am involved in SGA and we sometimes meet on the second
floor of the C building.” or “I spend a lot of time studying in the library in the LR building.”)
I, ___________________________, have read and understand the College of Southern
Maryland Emergency Guidelines for Individuals with Disabilities.
X______________________________________________
Parent/Guardian Signature:
___________________________
Date:
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