Fillable DISABIlITY INFORMATION SHEET | FORM TwO (Flint Hills Technical College)

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DISABIlITY INFORMATION SHEET | FORM TwO (Flint Hills Technical College)

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620.343.4600 | 800.711.6947 | fax: 620.343.4610 www.fhtc.edu 3301 West 18th avenue | emporia, Kansas 66801
DISABIlITY INFORMATION
SHEET | FORM TwO
CONFIDENTIAl DOCUMENT
To: Vice President of Student Services
Flint Hills Technical College
Name: Social Security Number:
Permanent Address:
Local Address:
Date: Home Telephone: Work Telephone:
Program of Study:
Disability is: Temporary Permanent
Disability Category:
Vision
Mobility/Ortho
Hearing
LD
Speech
Other
Rev. 11/25/2013
Last First
City State Zip
City State Zip
mm/dd/yyyy
Description of Disability:
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DISABIlITY INFORMATION SHEET FORM TwO (Flint Hills Technical College)

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Completed 25 July 2020

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