Revised: 4/2019
Craven Community College
Student Request for Accommodations Under the
Americans with Disabilities Act
If you believe you will require an accommodation to assist you in meeting your academic requirements, return this
completed form to the ADA Coordinator, Student Center, Room 121, 800 College Ct., New Bern, NC 28562. With this
form, submit the appropriate, current, psychological evaluation or medical records that document your disability.
NAME
FIRST
M.I.
LAST
STUDENT ID#
DATE OF BIRTH
DD
MAILING ADDRESS
STREET
APT#
CITY
STATE
ZIP
STUDENT EMAIL ADDRESS
PHONE
Please describe your disability
Please describe the limitations or current impact imposed by your disability
Please list your requested accommodations
Acknowledgement and Consent: I understand and acknowledge that the determination of whether any accommodations
of my disability requested by me will be made at the discretion of the College. In order to assist the College in making the
determination of whether accommodations are appropriate for my disability, I hereby consent to the release to the
appropriate personnel of any information contained in this form and any other information I have provided to the College
concerning my disability.
_____________________________________________ ____/____ /____
Student Signature Date
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