620.343.4600 | 800.711.6947 | fax: 620.343.4610 www.fhtc.edu 3301 West 18th avenue | emporia, Kansas 66801
REQUEST FOR ACCOMMODATION AND
ACADEMIC SUPPORT | FORM ONE
CONFIDENTIAl DOCUMENT
To: Vice President of Student Services
Flint Hills Technical College
Name: Social Security Number:
Address:
Home Telephone: Work Telephone:
IDENTIFY NATURE OF REQUIRED SERVICE OR ACCOMMODATION
Testing accommodation, if requested in a timely manner:
Academic support services:
Auxiliary aids:
Other:
I understand that I must provide medical or other diagnostic documentation of my disability and limitations, prepared by a qualied physician,
psychologist, or professional, to the Vice President of Student Services.
Student Signature: Date:
IT IS THE RESPONSIBILITY OF THE INDIVIDUAL STUDENT TO REQUEST ACCOMMODATION OR AUXILIARY AIDS AT LEAST SIX (6) WEEKS
BEFORE CLASSES, PROGRAMS, OR ACTIVITIES BEGIN.
AVAIlABIlITY OF AUXIlIARY AIDS
IT IS THE STUDENT’S RESPONSIBILITY TO MAKE WRITTEN REQUEST FOR ASSISTANCE IN OBTAINING SPECIALIZED SUPPORT SERVICES
FROM OTHER RESOURCES such as State Vocational Rehabilitation, Recordings for the Blind, State Services for the Blind, etc. For example, the
Division of Vocational Rehabilitation (DVR) may fund such items as transportation to the institution, tuition, text books, hearing aids, and other
individually prescribed devices.
Rev. 11/25/2013
Last First
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mm/dd/yyyy
By checking this box you have created an electronic signatureas legally
binding as your hand-written signature.
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