Fillable STUDENT ACCOMMODATIONS REQUEST FORM (Hawkeye Community College)

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STUDENT ACCOMMODATIONS REQUEST FORM (Hawkeye Community College)

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  • 20 check-boxes
  • 31 other fields

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File type: PDF

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STUDENT ACCOMMODATIONS REQUEST FORM
PERSONAL INFORMATION
Start Term:
Note: Please indicate the term when you would like to start your
services. Example: Fall 2020
Hawkeye Student ID#:
Hint: Provide the ID Number listed on the back of your student
ID, if available.
Full Legal Name:
Preferred Name (Optional):
Birth Date:
Hint: Enter date in the following format Month / Day / Year (i.e. 12/31/2000)
Gender:
Female
Male
Prefer not to Answer
Preferred Pronouns:
She / Her / Hers
He / Him/ His
They / Them / Theirs
Prefer not to Answer
CONTACT INFORMATION
Cell Phone Number: Alternate Phone Number:
Local Address:
City: State: Zip Code:
Email Address:
Hint: Hawkeye Student Accessibility Services will use the hawkeyecollege.edu address for all official email contact.
HAWKEYE STATUS
Enrollment Status:
Current Student
Concurrent Student
*High School Student & Hawkeye Student*
Business & Continuing Education
Student
Adult Learning Center Student
Prospective Student
Affiliations:
Athletics
TRiO
Veteran
Vocational Rehabilitation
Transitional Alliance Program (TAP)
International Student
Iowa Workforce
Program/Major:
*PLEASE CHECK THE BOX OR BOXES THAT BEST DESCRIBE YOUR ACCOMMODATION REQUESTS*
ACADEMIC
ACCOMMODATIONS
ACCUPLACER
ACCOMMODATIONS
TEAS
ACCOMMODATIONS
OTHER
ACCOMMODATIONS
DISABILITY IMPLICATIONS
*THESE QUESTIONS ARE TO BE COMPLETED BY THE STUDENT.*
Please describe your physical or mental disability, illness, condition, or disease.
Please describe how your disability affects, limits, or impacts your performance as a student.
If your disability creates a problem in class attendance, please explain how.
Please list the accommodation (s) you are requesting at Hawkeye. Please include any equipment, auxiliary aids,
assistive technology, and / or other services you may need while at Hawkeye.
I certify that the foregoing statements are complete, accurate, and true to the best of my knowledge. I also understand the
college may ask for further documentation from appropriate professionals for the purpose of establishing the existence and
extent of my disability, illness, condition, or disease and the relation to my need for a reasonable accommodation, if any.
Student Signature:
Date:
Complete and Return to:
Student Accessibility Services
Hawkeye Community College
P.O. Box 8015
Waterloo, IA 50704-8015
Fax: 1-319-296-1028
Email: accessibility@hawkeyecollege.edu
Phone: 1-319-296-4014
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STUDENT ACCOMMODATIONS REQUEST FORM (Hawkeye Community College)

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Completed 16 September 2020

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