PART 1: GENERAL INFORMATION
_____________________________ _____________________________ _______________
Last Name First Name Middle Initial
_____________________________ _____________________________
Date of Birth NCC Student ID#
_______________________________________________________________________________________
Mailing Address City, State, ZIP
_____________________________ May we leave a message on your voicemail? _______________
Phone Number
_________________________________________ _________________________________________
Student Email Address Personal Email Address*
* Once you have a NCC student email all correspondence is sent to your college email address.
__________________________________ OR I am ___Early College Student
What program are you in/applying for? ___ Running Start Student
Check all that apply: ___ Current NCC Student
___ Took ACCUPLACER
___ Applied to NCC ___Submitted SAT Scores
___ Registered for classes
PART 2: DIAGNOSES
1. List your diagnoses/disability: ____________________________________________________________
____________________________________________________________________________________
2. List assistive technology you use (ex. Wheelchair, FM System, etc.) AND/OR any outside agency you
work with (Voc Rehab, etc.): _____________________________________________________________
____________________________________________________________________________________
PART 3: GUARDIAN INFO
1. I am at least 18 years of age and am my own guardian ___
2. If no, please provide your guardian’s name: ________________________________________
If NO, please provide guardian documentation with this application if 18 years of age or older.
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REASONABLE ACCOMODATION PLAN APPLICATION
