Disability Resources
2800 S. Lonetree Rd.
Flagstaff, AZ 86005
Disability Resources (DR)
1-800-350-7122 x4323
FAX (928) 226-4103
Name (list any previous names if applicable) _______________________________________________________
Address: ______________________________________________________________________________
City: ________________________________ State: ________________ Zip: ________________________
Phone #: ____________________________ Alternative Phone # _________________________________
Email: _______________________________ Emergency Contact # _______________________________
May we contact you via email regarding this request? _____ YES ____NO
Date of Birth _____/_____/_____ CCC ID#: __________________ Comet ID # ___________________
Type of Disability:
____ Learning Disability/ADD ____ Hard of Hearing ____ Intellectual Disability
____ Physical Impairment ____ Deaf ____ Autism
____ Visual Impairment ____ Blind
____ Medical (please specify) _________________ ____ Psychological
____ Other ____________________________________________________________________________
Have you chosen a major? ____ YES ____ NO If yes, please list: _____________________________
Have you ever attended CCC? ____ YES ____ NO
Have you ever applied for DR services? ____ YES ____ NO
When do you plan to attend CCC? FALL SPRING SUMMER For what year ________
Which CCC campus/site will you attend? ____________________________________________________
Are you currently or have you been a client of Vocational Rehabilitation - RSA)? ___YES ___NO
V.R. Counselor: ________________________________ Location: _______________________________
Parent(s)/Legal Guardian: __________________________________________________________
(Please print names in full)
I understand that I must meet with the Disability Resource Coordinator and provide current
documentation of my disability in order to be eligible to receive accommodations. I certify that
the above information is accurate and true to the best of my knowledge.
Student Signature: _______________________________________ Date: _____/_____/_____
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