Date Requested ________________________
Access and Disability Services
8900 U.S. Highway 14
Crystal Lake, IL 60012
(815) 455-8676
(815) 479-7836 FAX
Room A256
This student has requested support services at McHenry County College. In order to provide
services we must have a verication of disability.
__________________________________________________ ____________________________________
Name Phone
Address City Zip
Certifying Professional—please provide the following information in full: attach test scores, reports,
and other relevant information. If there is more than one disability, indicate which disability is
primary and which is secondary.
1. Diagnosis and description of disability.
– OVER –
2. Recommended accommodations: please mark only those accommodations that are necessary as
a direct result of the student’s disability.
Extended Testing Time
Test Reader
Private Testing
Alternative Textbook Formats—E-les
Classroom aide
Other _____________________________________________________________
3. Additional comments/information that would help us better serve this student.
Certifying Professional and Title (physician, psychiatrist, psychologist, licensed counselor)
Print Name ______________________________________________________________________________
Address _________________________________________________________________________________
Date ____________________________________________________________________________________
Please mail or fax (fax number is (815) 479-7836) the completed form to
Access and Disability Services at MCC, Room A256.
Please include your office cover sheet or cover letter.
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