DISABILITY SERVICES INTAKE ASSESSMENT FORM
SOWELA Disability Services organizes services for qualified students with disabilities requiring reasonable
accommodations. Notifying SOWELA that you have a disability is optional.
If you have a disability and need to request accommodations, please complete the following information and return it to
Office of Student Services, 3850 Sen. J. Bennett Johnston Ave., Magnolia Building (13), Student Success Center. You will
also need to make an appointment for an intake meeting with Christine Collins or Cicely Williams (
o
ds@sowela.edu or
call 337-421-6947).
Name Student ID#
Phone E-Mail
Address _
City State Zip Code
If you are transferring from another college, please state the name of the college and list support services you have
received.
Are you receiving assistance from Veterans Administration? Yes No
Are you receiving assistance from LA Rehabilitation Services? Yes No
Academic Program:
H
ow does this disability impact you in the academic environment (how it impacts your learning):
Please indicate what kind of accommodations you are requesting:
Describe the documentation you intend to provide to support your request for accommodation and attach to this form,
if available.
S
tudent Signature
Date
SOWELA Technical Community College does not discriminate or harass on the basis of race, color, national origin, sex, gender, sexual orientation, disability,
age, religion, genetic marker, or any other characteristic protected by state, local or federal law, in our programs and activities. For inquiries regarding non-
discrimination policies: EEO/Title IX Officer: Dr. Fitzpatrick Anyanwu, (337) 421-6905 or (800) 256-0483; fitzpatrick.anyanwu@sowela.edu
; ADA Officer:
Christine Collins, (337) 421-6969 or Christine.collins@sowela.edu.
