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
DISABILITY SUPPORT SERVICES: REQUEST FOR ACCOMMODATIONS
“No otherwise qualified individual with a disability shall, solely by reason of his disability, be excluded from the
participation in, be denied the benefits of, or be subjected to discrimination under any program or activity
receiving Federal financial assistance.” - Section 504 of the Rehabilitation Act of 1973
A “qualified person with a disability” is defined as one who meets the requisite academic and technical standards
required for admission or participation in the postsecondary institution’s programs and activities.
Requesting For:
New Student Returning Student Interim Student Cont. Education/Drivers Ed.
General Information:
Name:
Today’s Date: _______________________ Date of Birth: ________________________________
Student ID Number: ________________
Social Security Number: ________________________
Primary Phone:
_________________________ Secondary Phone: ________________________
Street Address:
City: _______________ County: ________________ State: ________ Zip Code:
Email:
_______________________________________________________________
____________
___________________________________________________________________
___________________________________________________________________________
Campus Attending:
La Plata Leonardtown Prince Frederick Waldorf Hughesville
Other: ____________________
Armed Force Status:
Active Duty Veteran Not Applicable
Medication:
List any medications you are currently prescribed and/or taking and any side effects of these medications
that a
dversely affect your daily activities:
___________________________________________________________________________________
___________________________________________________________________________________
Employment Status:
Full Time _ Part Time _ Unemployed _
Placement Scores: New Students Only
English ____ Math ____ Reading ____
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
Previous Accommodations:
List accommodations received in previous academic environments: Write NA if not applicable
__________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________
List accommodations you are requesting:
Semester: __________ Year: __________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
Disability Information:
Check all documented disabilities that apply to you:
ADD/ADHD Attention Deficit Disorder Mental or Emotional Disorder: Specify Below
Arthritis (Severe)
Autism Spectrum Disorder or Asperger’s Syndrome Mobility Impairment
Cancer
Multiple Sclerosis
Cerebral Palsy Muscular Dystrophy
Diabetes
Orthopedic Impairment Specify Below
Epilepsy/Seizure Disorder
Hearing Impaired:
Psychiatric Disorder Specify Below
Deaf
Hard of Hearing PTSD - Post Traumatic Stress Disorder
Heart Condition Speech Impairment
Learning Disability: Specify Below
Spinal Cord Injury
Stroke
Loss of Limb Traumatic Brain Injury
Medical Disability: Specify Below Visual Impairment
Blind
Other: Low Vision
Schedule:
Class Instructor
Course
Type
Day(s) Time
(ex T:7-8,Th:1-2)
Building/
Room #
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
Class Descriptions:
For every class please include a description of the course and what activities it may require:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
High School Data: DO NOT FILL IF RETURNING STUDENT
High School Attended: ___________________________________________________________
Date of Graduation or Completion of High School or equivalent:__________________________
Did you participate in “Try College for a Day” at CSM?
La Plata Prince Frederick Leonardtown Did not attend
If so, what year(s)? ____________
Student Goals: Please describe the
goals you strive to achieve in your college experience.
These goals can be for personal gain, to transfer to a 4 year institution, associates degree, drivers Ed. or anything you feel relevant.
Continuing Education Program of Study: ______________________________________________
Expected Date of Completion: _______________________________________________________
By signing I guarantee the information provided is correct to the best of my abilities.
X Signature: _____________________________________________ Date: _________________
Parent or guardian if student is under 18:
X 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
Individuals 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
Disability Support Service for Students
La Plata
(301)-934-7614
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 ______________________
Disability ________________________________________________________
Special Needs in case of campus emergency:
Additional rele
vant 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.”)
DSS USE ONLY:
A meeting was held on ____________ and attended by: _________________________,
____________________________, ____________________________
Documentation was appropriate: Yes
No If no, list why:
___________________________________________________________________________________
Referral made to DORS: Yes No
If yes, date of referral:
___________________________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
I, __________________________________, have read and understand the College of
Southern Maryland Emergency Guidelines for Individuals with Disabilities.
Signature: _____________________________________________ Date: _________________
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