dent Success Center
Request for Section 504 & ADA
Please provide all information requested for WDT to assist in helping you meet your
educational goals.
For help completing this form, please contact Jennifer Williams-Curl at (605)718-2904 or
Date: Student ID #:
Current Address:
City: State: Zip Code:
Phone Number: Program:
To expedite the process, please provide a copy of your most recent Individualized Education
Plan (IEP), 504 Plan, or evaluation documents. Students with disabilities are required to
provide medical and/or other appropriate diagnostic evaluation to help support your ADA
request. Documentation must include (as appropriate) physical description, medical or clinical
cautions, and recommendations for necessary accommodations in an academic setting.
Do you receive assistance from Vocational Rehabilitation Services? Yes No
If yes, please provide name and phone number of your Rehabilitation Counselor:
Do you require assistance for personal needs on campus? Yes No
If yes, please note them here:
Rev: March 2020
Rev: March 2020
Please indicate all verified disabilities specific to your circumstances:
Learning Disability
Neurological Condition
Psychological/Psychiatric Condition
Asperger’s / Autism
Attention Deficit Disorder
Respiratory Condition
Health Impairment
Other (please specify):
Are you currently taking medication? Yes No
If yes, please check one box:
Please identify only those medications with side effects and what you experience
when taking them (ex: drowsiness, irritation, jitters, etc.)
I have not experienced any side effects with my current medications
Please check any adaptive equipment that you currently use on a regular basis:
Cane Laptop
Magnification equipment Wheelchair
Communication device Speech device
Tape recorder Lap board
Other (please specify):
Have you been, or are you frequently, absent from school due to your disability?
No If yes, please explain.
Did you receive support or special services
for your disability while in high school?
Yes No If yes, please describe.
Check all accommodations or services that you received in the past or may need in the
future. Please note that not all accommodations may be available at this time.
Extended time on tests/quizzes - up to 1.5x
Enlarged material
Accessible classroom
Alternate testing room or
reduced-distraction setting
Oral tests
Taped lectures
Preferential seating
Other (please specify):
Statement of agreement:
I understand that the WDT Disability Coordinator has access to my academic files and
other WDT records in order to provide the support services I am requesting. I also
understand that the Disability Coordinator may need to contact my faculty or other
campus officials; which may also require disclosure of information about my disability and
needs. I understand that it is my responsibility to notify the Disability Coordinator of any
change in my medical status or special needs. By completing this form, I consent to
such disclosures except that I do not want the following persons/offices to receive
personal information about my disability:
FERPA: Do you want to authorize anyone else to request information or discuss your
academic, financial, or ADA/504 accommodation records?
Yes No
______________________________________________ ________________
Student Signature Date
Return to:
Jennifer Williams-Curl
Disability Services Coordinator
Western Dakota Tech
800 Mickelson Dr.
Rapid City, SD 57703
Rev: March 2020
Office Use Only:
Type of document(s) provided:
Most recent IEP
Most recent 504 Plan
Testing & Evaluation Report
Letter from Medical Provider
Voc Rehab Documentation