Fillable Office of Students with Disabilities APPLICATION FOR ACCOMMODATIONS (Florida Keys Community College)

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Office of Students with Disabilities APPLICATION FOR ACCOMMODATIONS (Florida Keys Community College)

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75.48 Office of Students with Disabilities August 2019
Office of Students with Disabilities
APPLICATION FOR ACCOMMODATIONS AND SERVICES
Students who are seeking accommodations and services on the basis of a disability are required to submit
documentation of their disability to the Office of Students with Disabilities. In accordance with State Board of
Education Rule 6A-20.111(2), the documentation must be sufficiently recent, as determined by the Office of
Students with Disabilities. Documentation should include a valid and reasonable assessment of the student’s
needs; be specific and conclusive, demonstrating that the student has physical, emotional or mental
impairment(s) which substantially limit(s) one or more major life activities, as well as showing how the
disability will substantially limit the student’s ability to meet the minimum full-time load requirements.
The Office of Students with Disabilities maintains the right to reject documentation that does not verify a
student’s disability or justify the need for reasonable accommodations and maintain the option of seeking a
second, professional opinion regarding documentation presented to verify disabilities. Documentation costs are
borne by the student, as are costs of obtaining additional documentation and must be on file with the Office of
Students with Disabilities in order for appropriate services to be provided.
In accordance with State Board of Education Rule 6A-20.111(1), the documentation submitted must be prepared
by a professional who has expertise in the area related to the disability in question and be a licensed physician; a
licensed psychologist; a licensed school psychologist; a certified school psychologist; a licensed audiologist; a
licensed speech-language pathologist; or, a certified school speech-language pathologist.
Name:
Student ID #:
Phone Number:
CFK Email:
Disability: ☐Hearing ☐Physical ☐Psychological ☐Speech ☐Visual
☐Specific Learning Disability ☐Autism Spectrum ☐ADHD
☐Anxiety Disorder ☐Traumatic Brain Injury ☐Intellectual Disability
☐PTSD ☐Other___________________________________________
__________Please initial here to give permission to the Office of Students with Disabilities to release any
medical/ psychological/ psychoeducational documentation to the following agency:
Agency Name:
Phone Number:
Address:
City, State, Zip Code:
75.48 Office of Students with Disabilities August 2019
I am requesting the following services to accommodate my disability:
☐Enlarged Print ☐Extended Time Testing ☐Interpreter ☐Note Taker
☐Reader for Tests ☐Priority Seating ☐Private Room Testing ☐Limited Distraction Testing
☐Use of a Computer ☐Other _________________________________________________________________
I am requesting the following equipment to accommodate my disability:
☐Table ☐Chair ☐Tape Recorder ☐Smart Pen
☐Other______________________________________________________________________
Please initial here to give permission for the Office of Students with Disabilities to share with
members of the administration and/or faculty any classroom diagnostic and/or instructional information
pertaining to me for the purpose of assisting me in my studies and coursework.
I understand that the Office of Students with Disabilities will keep a copy of my documentation for 3 years after
my last term of attendance. The College is not responsible for supplying me with copies of my documentation or
sending copies to other institutions. I understand that I should retain my original documentation for future use.
I understand that services are approved on a case-by-case basis and documentation of the disability must support
the requested accommodations. It is the student’s responsibility to notify the Office of Students with Disabilities
of any changes or concerns with a schedule, instructor, or accommodation. I must contact the Office of Students
with Disabilities each semester to request accommodations.
By signing I am acknowledging that I understand and agree to the Office of Students with Disabilities policies
and procedures as outlined above. I understand that I am responsible for communicating my needs to the
Coordinator for the Office of Students with Disabilities. I must communicate with my instructors in regard to my
accommodations and needs. I also understand that I am responsible for following the course syllabus and
attendance policy for each course.
Student Signature:
Date:
Office of Students
with Disabilities
Staff Signature:
Date:
Do you want to register to vote?
☐Yes ☐No
Do you want to update your existing voter
registration?
☐Yes ☐No
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Office of Students with Disabilities APPLICATION FOR ACCOMMODATIONS (Florida Keys Community College)

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Completed 25 July 2020

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