APPEAL OF DENIAL OF REASONABLE ACCOMMODATION REQUEST
Applicant Name: Date:
Program of Study:
Date of denial of reasonable accommodation request:
Accommodation that was denied (what was requested?):
Reason for appeal:
Additional supporting information: Yes No (If yes, attach copies of further medical or supporting information.)
Alternative accommodation requested: Yes No
Applicant Signature: Date:
* Send appeal to the Vice President of Student Services *
Flint Hills Technical College
3301 West 18th Avenue, Emporia, KS 66801
(Attach a copy of original request and denial.)
Last First
FHTC OFFICE USE ONLY:
In order to provide the student with special educational services designed to help him/her be more successful in college, we require a
verication of the students disability. Please provide the following information:
APPROVED
DENIED
ALERNATIVE ACCOMMODATION
Comments:
Signature:
Date received: Date of decision:
mm/dd/yyyy
mm/dd/yyyy
620.343.4600 | 800.711.6947 | fax: 620.343.4610 www.fhtc.edu 3301 West 18th avenue | emporia, Kansas 66801
CONFIDENTIAL
Rev. 11/25/2013
By checking this box you have created an electronic signatureas legally
binding as your hand-written signature.
By checking this box you have created an electronic signatureas legally
binding as your hand-written signature.
