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One College Drive,
PHONE (413
FAX (413
Voluntary Statement of Learning Needs
In compliance with Section 504 of the Rehabilitation Act and the Americans with Disabilities Act Amendments Act
(ADAAA) of 2008, GCC, an affirmative action/equal opportunity institution, offers accommodations for eligible students
with documented disabilities.
Prior to your initial meeting with the Coordinator of Disability Services, you will need to complete both sides of this
form and send it, along with any supporting documentation you may have, to our office.
The fastest and most secure method of sending us your documents is to upload them using this link:
You may also send documents to our office by postal mail (to above address) or fax (413-774-7884).
Please note that information sent by postal mail or fax will slow processing.
We do not recommend using email because it’s not secure; but, should you choose to use this method, please send
your email with the document attachments to DisabilityServices@gcc.mass.edu.
IMPORTANT - The information you provide on this form will assist the Coordinator in assessing what academic
accommodations may be applicable for your disability or situation, and ensures information you want the Coordinator
to know is not forgotten during the course of the conversation.
Part A - Identification and Contact Information
Name ________________________________________ Birth Date ___/___/_____ Student ID # ___________
your cell your home
your cell your home
someone else’s ______________
someone else’s ________________
Primary Phone Number ____________________
Secondary Phone Number ____________________
Preferred First Name __________________________
Pronoun _______________________
Part B - Disability Disclosure
In your own words, please describe your disability or situation and how it impacts you in the academic environment.
Disability Diagnosis/Diagnoses
Describe how your disability or situation impacts your academic success
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Part C - Academic Accommodations
If there are specific academic accommodations that you’d like to discuss with the Coordinator of Disability Services, use
the space below to briefly describe the accommodation(s). Regardless of whether you specify accommodations or
choose to leave this section blank, the Coordinator will advise you of all accommodations related to your disability or
situation which may be available to you while attending classes at GCC.
Special Permit Parking requests are handled by the GCC Public Safety Office.
For information about special permit parking, go to http://www.gcc.mass.edu/safety/parking/.
The GCC Public Safety Office is located in S110 (Main Campus Building) and may be reached by calling (413) 775-1212.
Part D - External Support
If you would like the Coordinator of Disability Services to know that you receive external support, check all applicable
boxes from the following list or use “Other” to write-in the name of an external support.
Mass Rehab Commission
Mass Commission for the Blind
Clinical & Support Options
Veterans Affairs
Mass Commission for Deaf and Hard of Hearing
Mass Department of Mental Health
Service Net
Other ___________________________________________________
Part E - Consent
If after reading this section, you understand and agree to the following consent statements, please sign and date below.
However, if you have questions, do not sign below until you have discussed your questions with the Coordinator of
Disability Services and are clear about what you are agreeing to.
I authorize GCC’s Office of Disability Services to review my disability related documentation that I’ve either
provided or released to Disability Services in order to determine eligibility for academic accommodations and to
compose an Accommodation Agreement on my behalf which specifies my eligibility for and lists the
accommodations that are reasonable to use while at GCC.
I authorize GCC’s Office of Disability Services to disclose information related to my disability needs to appropriate
College personnel participating in the accommodation process or working on my behalf for the purpose of ensuring
that reasonable and appropriate services are in place to assist me.
I have read, understand, and agree to the above terms.
________________________________________________________ _________________________
Student’s Signature
Date Signed