Online Student Application

Disability Diagnosis: *

Date of Diagnosis: *

Current Medication (if applicable) and list of side effects that may impact your educational experience. *

How does your disability impact you in an educational/academic environment? *

Please list an academic accommodations and/or services you used in high school, if applicable: *

Please list any colleges previously attended and any academic accommodations and/or services used there, if applicable: *

Please list any accommodations that you used on any national or state standardized exams (SAT, ACT, CNA, etc.), if applicable: *

Please list any auxiliary aids, equipment, assistive technology, and/or other services you anticipate using while attending JCCC. *

Do you need accommodations for any of the following? Please check all that apply: (leave blank if not applicable)

Internship Courses

Field Trips

Clinical Courses

Labs (Art, Science, Vocational, etc.)

Other (Specify Below): (Specify Below)

Additional Note or Comment

Please list any academic accommodations you are requesting that were not listed previously on this application: *

Please share any additional information that would assist us in providing you with reasonable accommodations in your classes: *

How did you hear about Access Services?

Counseling Center

Family Member

High School

Professor

Vocational Rehabilitation

Other (Specify Below)

Additional Note or Comment

Are you currently working with a JCCC Academic Counselor? If yes, please list the name of your counselor. *

Yes

No

Additional Note or Comment