Fillable Student-accessibility-services-application Student Accessibility Services Application

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Student-accessibility-services-application Student Accessibility Services Application

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Indian River State College
Student Accessibility Services Application
In order to be eligible for Student Accessibility Services (SAS) at IRSC and to receive
accommodations, complete the items below. Submit your documentation and completed
Student Accessibility Services forms to the SAS counselor, SAS advisor or SAS campus liaison.
1. Complete checklist on Required Documentation of Disability Guidelines (pages 2-3).
2. Complete the Student Accessibility Services Identification Form (page 4).
3. Complete checklist of Accommodations and Access Needs (page 5)
4. Sign the Agreement of Services (page 6).
5. Complete the Voter Registration Preference Card* checklist (page 7).
*Please note that we are required by law to offer assistance with becoming a registered voter if desired.
Your choice does not impact your eligibility for accommodations, equipment or services.
Student Accessibility Services Contact Information
Sherise Hobson
SAS Counselor, Main Campus
Phone: 772-462-7782
Email: shobson@irsc.edu
Jacquelene Burke
SAS Advisor, Main Campus
Phone: 772-462-7808
Email: jburke@irsc.edu
Ruby Jefferson
Mueller Campus SAS Liaison
Annie Galland
Pruitt Campus SAS Liaison
Janine Merriman
Dixon Hendry Campus SAS Liaison
C. Leigh Chappell
Chastain Campus SAS Liaison
For Office Use Only
SAS Counselor/Advisor Date Received
Page | 1
Required Documentation of Disability Guidelines
All documentation must be on lettered, dated and signed by a licensed or certified clinical
professional who is qualified to make the diagnosis. Documentation must include a diagnosis and
a description of the impact to educational access or experienced limitations. Documentation may
be electronically signed.
Indicate (below) whether you have one or more of the following disabilities, which may require
accommodations in a college environment or with curriculum.
Specific Learning Disability
☐ Psychological, neuropsychological, or psycho-educational evaluation within the past 5 years
signed by a licensed psychologist. Evaluation must include diagnosis and description of impact
to educational access.
OR ALL LISTED BELOW
☐ Psychological, neuropsychological, or psycho-educational evaluation no matter the date,
signed by a licensed psychologist. Evaluation must include diagnosis and description of impact
to educational access.
☐ IEP with accommodations included that is dated within the past 5 years.
☐ Eligibility and Assignment Staffing form signed by the school psychologist with
diagnosis/exceptionality listed within the last 5 years. If Eligibility and Assignment Staffing form
is not available, is not signed by the school psychologist, or no diagnosis/exceptionality is listed
then a signed letter from the school psychologist within the past 5 years on letterhead, indicating
diagnosis/exceptionality can be used as an alternative.
Speech/Language Impairment
☐ Speech/language, psychological, neuropsychological, or psycho-educational evaluation
within the past 5 years signed by a licensed psychologist or speech/language pathologist.
Evaluation must include diagnosis and description of impact to educational access.
OR ALL LISTED BELOW
☐ Speech/language, psychological, neuropsychological, or psycho-educational evaluation no
matter the date, signed by a licensed psychologist or speech language pathologist. Evaluation
must include diagnosis and description of impact to educational access.
☐ IEP with accommodations included that is dated within the past 5 years.
☐ Eligibility and Assignment Staffing form signed by school psychologist or speech/language
pathologist with diagnosis/exceptionality listed within the last 5 years. If Eligibility and
Assignment Staffing form is not available, is not signed by school psychologist or
speech/language pathologist, or no diagnosis/exceptionality is listed then a signed letter from
the school psychologist or speech/language pathologist within the past 5 years on letterhead,
indicating diagnosis/exceptionality can be used as an alternative.
Deaf/Hard of Hearing
☐ Audiogram within the past 5 years and a signed letter from a medical doctor within the past 5
years that includes a diagnosis and description of impact to educational access. If the letter from
the medical doctor is dated older than 5 years then a copy of an IEP or 504 plan can be used to
supplement the letter.
Page | 2
Visual Impairment
☐ Letter from a medical doctor within the past 5 years that includes a diagnosis and description
of impact to educational access. A vision examination report within the past 5 years signed by
Ophthalmologist that includes a diagnosis and description of impact to educational access may
also be used.
Orthopedic Impairment
☐ Letter from a licensed or certified clinical professional qualified to make the diagnosis dated
within the past 5 years that includes a diagnosis and description of impact to educational access.
Emotional or Behavioral Disability
☐ Letter from a licensed or certified clinical professional qualified to make the diagnosis dated
within the past 5 years that includes a diagnosis and description of impact to educational access.
Autism Spectrum Disorder
☐ Letter from a licensed or certified clinical professional qualified to make the diagnosis dated
within the past 5 years that includes a diagnosis and description of impact to educational access.
Traumatic Brain Injury
☐ Letter from a licensed or certified clinical professional qualified to make the diagnosis dated
within the past 5 years that includes a diagnosis and description of impact to educational access.
Other Health Impairment
☐ Letter from a licensed or certified clinical professional qualified to make the diagnosis dated
within the past 5 years that includes a diagnosis and description of impact to educational access.
Intellectual Disability
☐ Psychological, neuropsychological, or psycho-educational evaluation within the past 5 years
signed by a licensed psychologist. Evaluation must include diagnosis and description of impact
to educational access.
OR ALL LISTED BELOW
☐ Psychological, neuropsychological, or psycho-educational evaluation no matter the date,
signed by a licensed psychologist. Evaluation must include diagnosis and description of impact
to educational access.
☐ IEP with accommodations included that is dated within the past 5 years.
☐ Eligibility and Assignment Staffing form signed by the school psychologist with
diagnosis/exceptionality listed within the last 5 years. If Eligibility and Assignment Staffing form
is not available, is not signed by the school psychologist, or no diagnosis/exceptionality is listed
then a signed letter from the school psychologist within the past 5 years on letterhead, indicating
diagnosis/exceptionality can be used as an alternative.
Page | 3
Student Accessibility Services Identification
In order to provide accommodations, IRSC is asking for voluntary self-identification of students
with a disability. This information will be kept confidential and will be used for the sole purpose
of aiding you in achieving your academic access.
Name Student ID#
Cell Phone# Preferred email
Please list all agencies you are a client with. If you have a specific contact person at the agency
include their name and contact information along with any accessibility equipment or services
you are currently receiving.
How did you learn about Student Accessibility Services at IRSC?
Have you completed a Release of Records at IRSC? If you have, please write their name and
preferred contact information.
Program of Study
☐ A.A. Degree ☐ A.S./A.A.S. Degree ☐ B.S./B.A.S. Degree ☐ Non-Degree
☐ Certificate ☐ Vocational ☐ Undecided ☐ GED
®
Intended major
Semester you pla
☐ Fall
n to begin courses at IRSC:
☐ Spring ☐ Summer Year: 20
GED® is a registered trademark of the American Council on Education (ACE) and administered
exclusively by GED Testing Service LLC under license. This material is not endorsed or approved by ACE
or GED® Testing Service.
Student Signature Date
Page | 4
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Accommodations and Access Needs
Indicate (below) the accommodations you may need and are supported or referenced in the
documentation of your disability. Additional documentation will be requested if a requested
accommodation is not supported by the documentation provided. Accommodations will only be
available after the completion of SAS application requirements. Please note accommodations
are not retroactive. Some accommodations, equipment or services require additional forms to
be completed.
Accommodations
☐ Extended time for testing
☐ Distraction reduced environment for testing
provided by the Assessment Center
☐ Note-taking assistance
☐ May stand/stretch/leave class periodically
☐ Instructor speak clearly facing the student
☐ Preferential seating in the classroom
☐ Provision for disability related absence
☐ Substitution or waiver of course or requirement
☐ May audio record class lectures
☐ Use of personal FM device in class
☐ Alternative format text for course materials
☐ JAWS
☐ Dragon Naturally Speaking
☐ Use of hand held magnifier
☐ Use of stationary magnifier for testing
☐ Use of personal FM device in class
☐ TDD/TTY access
☐ Real time captioning
☐ Use of 4-function calculator
☐ Closed Captioning
☐ Reader and/or Scribe for classroom
and/or testing
☐ Sign Language Interpreter
Describe how your disability impacts your access to education, learning or facilities.
What accommodations have you used in the past that have been effective and why?
Page | 5
Agreement of Services
I, Student ID Number:
acknowledge that I have access to the Student Accessibility Services Handbook. An SAS
Counselor/Advisor discussed with me my accommodations and access needs. Together we
agreed upon appropriate and reasonable accommodations, services and equipment at IRSC to
remove disability related barriers. I have been informed that notices will be emailed to me at my
IRSC Rivermail email account and to my instructors each semester I register for courses
regarding the accommodations I am eligible to receive and the procedures. I understand that it
is my responsibility to discuss the accommodations needed at the beginning of each semester
with my instructors. My responsibility to participate in the discussion of and advocacy for my
accommodations cannot be transferred to another person or abdicated. I understand
accommodations/access services are not retroactive.
I am aware that if there needs to be a change in the accommodations I am receiving, if I have
any concerns relating to the accommodations, if I am not receiving the accommodations or if I
am in need of additional accommodations, it is my responsibility to contact Student Accessibility
Services for assistance. And, if I make a request for additional accommodations, course
substitutions, prep course or TABE waivers, additional documentation or forms may be required.
If the auxiliary learning aid assistance or equipment requested is not available to me from any
state or federal program responsible for such assistance, IRSC will support the access need as
quickly and effectively as possible. If the exact services or equipment are not readily available
through SAS the student and SAS counselor/advisor will collaboratively discuss the access
need and determine a reasonable alternative accommodation. If currently a client of another
agency, I will inform Student Accessibility Services if financial benefits for auxiliary aids are
changed and in any event, I will contact or authorize permission to be referred to another
appropriate agency for possible sponsorship and will inform Student Accessibility Services of
the results of the meeting.
I understand that due to my disability, if I am allowed to record classroom lectures that material
is to be used solely for my personal academic enrichment and cannot be distributed, copied,
sold or uploaded to the web. I also understand that recorded lectures may not be used in any
way against the faculty member, other lecturer, or students whose classroom comments are
recorded as part of the class activity.
I give permission to allow the SAS counselor/advisor to notify my instructors, the Assessment
Center of my accommodations each semester and to discuss my academic progress.
Discussion of disability specific information with appropriate college personnel will only occur
when deemed necessary for safety or with written permission by the student. Furthermore, I
understand that only Assessment Center staff and IRSC instructors are allowed to proctor tests-
not readers, scribes, note-takers, family or friends. I agree to release IRSC, its agents and
employees from any and all liability and hold it and those harmless from any and all claims and
causes of action caused by or arising from the accommodations received.
Student Signature Date
Page | 6
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Voter Registration Preference Form
Check the box only in 1. or 2.
If you do not check any box, it will be considered that you chose not to register or update your
voter registration at this time.
1. If you are not registered to vote where you live now, would you like to apply to register
to vote today?
☐ Yes ☐ No, I decline.
2. If you are registered to vote where you live now, would you like to update your voter
registration record?
☐ Yes ☐ No, I decline.
Signature: Date:
Notice of Rights
Help: If you would like help in filling out your voter registration application, we will help you.
The decision whether to seek or accept help is yours. You may fill out the voter registration
application in private.
To Register to Vote in Florida, You Must:
• Be a U.S. citizen (a lawful permanent resident cannot register or vote)
•
Be at least 18 years old (you may pre-register if you are at least 16 years old although
you cannot vote until you are 18 years old)
•
Be a Florida resident
•
Have had your right to vote restored if you have ever been convicted of a felony
• Have had your right to vote restored if a court has ever declared you to be mentally
incapacitated as to your right to vote. If you do not meet these requirements, you are
not eligible to register.
You Can Register to Vote at:
• Any Supervisor of Elections’ office
•
Any driver’s license office or tax collector’s office that issues driver’s licenses
•
Any voter registration agency (that is, any public assistance office, any office that
provides services for persons with disabilities, any center for independent living, any
armed forces recruitment office or any public library)
•
The Division of Elections (Florida Department of State)
Page | 7
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Completed 3 November 2019

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