LEHIGH CARBON COMMUNITY COLLEGE
REQUEST FOR ASSISTANCE DUE TO TEMPORARY IMPAIRMENT
To receive consideration, the student must complete and submit the Request for Assistance Due
to Temporary Impairment. Documentation from the student’s treatment provider, describing the
temporary
limitation must also be submitted with the request. Submit all documents to the
Educational Support Center located in Science Hall, SH 150, or email the Director of Learning
Support, Karen Ladley, kladley@lccc.edu.
Students are strongly encouraged to submit requests as soon as possible, so that assistance can
be provided promptly within the semester. Complete this Request for Assistance Due to
Temporary Impairment form and submit it to the Educational Support Center located in Science
Hall, SH 150. Upon receipt of it and the medical documentation, all requests will be handled in a
timely manner.
Semester/Year:
Date: _
Student
Name: ________________________________ _ Student ID: ___________________
Student Email: __________________________________ Student Phone: ________________
Courses for which assistance is requested:
1.
2.
3.
4.
5.
Yes No
Doc
umentation of temporary impairment attached:
Assistance requested:
Submit request to:
Educational Support Center
SH 150
4525 Education Park Drive
Schnecksville, PA 18078
Phone: 610-799-1156
Fax: 610-799-1068
Email: kladley@lccc.edu
PERM24A-w (AC)
