Fillable Disability Services Semester Accommodation Request Form Please indicate (SOWELA Technical Community College)

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Disability Services Semester Accommodation Request Form Please indicate (SOWELA Technical Community College)

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The Disability Services Semester Accommodation Request Form Please indicate (SOWELA Technical Community College) form is 2 pages long and contains:

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  • 14 check-boxes
  • 18 other fields

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File type: PDF

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Disability Services
Semester Accommodation Request Form
Please indicate every semester you will need services for the school year.
Semester Accommodations being requested: Fall Spring Summer
Mid-Semester 20 __
Name: _____________________________________________________ Date: __________________
Student ID# _______________________________
Address: _______________________________________________________ Zip Code: _________
Telephone: ____________________ Cell: ________________ STCC E-mail: _________________
Disability: _________________________________________________________________________
In case of Emergency, who may we contact? Name ________________________ Phone: _________
Did you receive accommodations last semester? Yes No
Are you planning to return next semester? Yes No
If transferring, where are you going? _____________________________________________________
National Voter Registration Act: If you require assistances re-certifying, renewing, or changing
your address please check one:
Yes No
Student Agreement
I understand the responsibility for obtaining reasonable accommodations in the classroom is mine.
I understand if I am requesting new accommodations, I must meet with my DS Counselor prior to having these
accommodations approved.
I understand that if I am testing in the Disability Services, a completed testing form signed by myself and my
instructor must be submitted to the Disability Services three (3) days prior to each exam. I also understand that
during finals, I am encouraged to have the testing request forms submitted at least one (1) week in advance.
I understand that I am responsible for following the Disability Services policies and procedures outlined in the
Disability Services Student Handbook and that failure to comply with these policies and procedures may result
in my not receiving accommodations.
I understand that if I request note taking services through Disability Services, my e-mail address will be posted
in the Note Taker Packet. (If this is a problem, please speak with your DS Counselor.)
I understand that my SEMESTER ACCOMMODATION LETTERS will be sent to my instructors, unless a
written letter has been given to the office stating otherwise.
I understand it is my responsibility to discussed my semester accommodation letter with my instructor at the
beginning of the semester. (ACCOMMODATIONS ARE NOT RETROACTIVE.)
I agree to and understand the conditions stated above.
Student’s Signature: ___________________________________ Date: ___________________
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STATE OF LOUISIANA
VOTER REGISTRATION AGENCIES
DECLARATION FORM
If you are not registered to vote where you live now, would you like to apply
to register to vote here today? (Check one)
[ ] I want to register to vote. [ ] I do not want to register to vote.
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE
DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.
Applying to register or declining to register to vote will not affect the amount of assistance that you will be
provided by this agency. Voter eligibility requirements are found on the voter registration application form.
Note: If you do register to vote, the location where your application was submitted will remain
confidential. If you decline to register to vote, this fact will remain confidential. Applying to register or
declining to register to vote will be used only for voter registration purposes.
If you would like help in filling out the voter registration application form, we will help you. The
decision whether to seek or accept help is yours. You may fill out the application in private.
(Check one)
[ ] Yes, I would like help. [ ] No, I do not want help.
For assistance in completing the voter registration application form outside our office, contact
Student Services at (337) 421-6947 or ods@sowela.edu.
If completed outside our office, this declaration form and your completed voter registration application
form (if you filled one out) should be returned to SOWELA, 3850 Sen. J Bennett Johnston Ave.,
Magnolia Building- Student Success Center, Lake Charles, LA 70615.
Signature or Mark Name Typed or Printed Date
Signatures of Two Witnesses If Signed With Mark:
1) ____________________________________ 2)_______________________________________
COMPLAINTS
If you believe that someone has interfered with your right to register or to decline to register to vote, your
right to privacy in deciding whether to register or in applying to register to vote, or your right to choose
your own political party or other political preference, you may file a complaint with the Louisiana Secretary
of State, Commissioner of Elections, P.O. Box 94125, Baton Rouge, LA 70804-9125 or by calling
(225)922-0900 or 1-800-883-2805.
C
omments/Remarks (for official use only):
NVRADF Rev. 3/13
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Disability Services Semester Accommodation Request Form Please indicate (SOWELA Technical Community College)

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Completed 17 September 2020

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