DISABIlITY FORM B
Rev. 11/25/2013
Psychologist, ect.
AUTHORIZATION FOR RElEASE OF INFORMATION BY lICENSED PSYCHOlOGIST OR PROFESSIONAl
To
Day Time Phone Evening Time Phone
I, the undersigned student, am requesting special services from Flint Hills Technical College and hereby request and authorize you to release any
information pertaining to my disability.
Students Full Name
Date of Birth Social Security Number - -
Signature of Student Date
Last First Middle JR., etc.
Street Address
City State Zip
DISABIlITY VERIFICATION
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:
Diagnosis
Limitations Functional limitation(s) resulting from the condition/disorder that would, in your opinion impede the student’s
educational performance. Please check all that apply:
Poor concentration, distractibility and/or confusion.
Intense anxiety, phobia, and/or panic.
Difculty completing assignments due to pressures.
Difculty in taking notes, reading college texts, taking tests and/or managing time.
Problems in hearing and/or speaking in class discussions.
Other
Signature of Professional
Title Date
After a qualied professional has completed the disability verication section, please mail to: Flint Hills Technical College, Attn: Vice President of
Student Services, 3301 West 18
Th
Avenue, Emporia KS 66801. Or email the completed pdf to lkirmer@fhtc.edu.
mm/dd/yyyy
mm/dd/yyyy
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.
