Fillable Form 9: Accommodation Request Form (Walla Walla Community College)

Fill Online, Printable, Fillable, Blank Form 9: Accommodation Request Form (Walla Walla Community College) Form

Use Fill to complete blank online WALLA WALLA COMMUNITY COLLEGE pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Form 9: Accommodation Request Form (Walla Walla Community College)

On average this form takes 34 minutes to complete

The Form 9: Accommodation Request Form (Walla Walla Community College) form is 2 pages long and contains:

  • 0 signatures
  • 11 check-boxes
  • 132 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Walla Walla Community College

BROWSE WALLA WALLA COMMUNITY COLLEGE FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
W W C C
Accommodation Request Form
Please complete this form as part of your request for disability support services.
If you need assistance to complete the form contact: Walla Walla Campus - Bobbie Sue Arias, Coordinator of Disability Support
Services at (509)527-4262 or bobbiesue.arias@wwcc.edu. Clarkston Campus - Heather Markwalter, Coordinator of Disability
Support Services at (509)758-1721 or heather.markwalter@wwcc.edu
STUDENT INFORMATION
Date: Student Status: Prospective Current
Last Name: First Name: Middle Initial:
Student ID#: Birth date (mm/dd/yyyy):
Permanent Address:
City: State: Zip code:
Home Phone: Cell Phone:
E-mail address:
Program of Study: AA/AS Transfer Undecided
(Please check the one that applies) Professional/Tech ___________________ Other __________________
WWCC Advisor:
Are you a Vocational Rehabilitation client? Yes No I’d like to learn more
Please identify the disability and indicate if you will provide supporting documentation:
*Documentation is usually provided by a physician, psychologist, learning disabilities specialist, or
rehabilitation counselor.
Can Provide Documentation:
________________________________________________ Yes No
________________________________________________ Yes No
________________________________________________ Yes No
M D S E
Describe the barriers you encounter due to your disability that prevent you from accessing the educational
environment.
•
W
A
L
L
A
W
A
L
L
A
C
O
M
M
U
N
I
T
Y
C
O
L
L
E
G
E
•
E
S
T
A
B
L
I
S
H
E
D
1
9
6
7
FUNCTIONAL LIMITATIONS
Please check the level of limitation you experience as a result of your disability.
C : No Mild Moderate
Substantial
L:
No Mild Moderate
Substantial
O Impact Impact Impact Impact Impact Impact Impact Impact
Speaking  Reading 
Hearing  Writing 
Breathing  Spelling 
Seeing  Calculating 
Walking  Memorizing 
Liing/
 Concentrating 
Carrying
Sitting  Listening 
Performing
 Organizing 
Tasks
Eating  Communicating 
Interacting

Other:
with others
Sleeping 
Standing 
Bodily

Functions
ACCOMMODATION REQUESTS
I am requesting (check all that apply):
Academic Accommodations(s) (e.g.: classroom, exams, e-text, etc.)
Campus accessibility (e.g.: doorways, elevators, lights, etc.)
Please list the accommodations you are requesting:
Please describe your previous educational experiences and the services you have received in the past (i.e., can be from
high school Special Education or 504 plan, accommodations on the ACT/SAT/GRE test, accommodations received at
other institutions of higher education, etc):
I agree that the disability coordinator may change my registration form from a “no” to a “yes” (if I have not al-
ready marked as such) to indicate that I am an individual with a disability.
Signature________________________________________________
I would like information about voter registration: Yes No
SUBMIT WW
SUBMIT CLRK
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Form 9: Accommodation Request Form (Walla Walla Community College)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document