Online Student Application

Questions

1. Disability Diagnosis:
2. Date of Diagnosis:
3. Current Medication (if applicable) and list of side effects that may impact your educational experience.
4. How does your disability impact you in an educational/academic environment?
5. Please list an academic accommodations and/or services you used in high school, if applicable:
6. Please list any colleges previously attended and any academic accommodations and/or services used there, if applicable:
7. Please list any accommodations that you used on any national or state standardized exams (SAT, ACT, CNA, etc.), if applicable:
8. Please list any auxiliary aids, equipment, assistive technology, and/or other services you anticipate using while attending JCCC.
9.  

   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
10. Please list any academic accommodations you are requesting that were not listed previously on this application:
11. Please share any additional information that would assist us in providing you with reasonable accommodations in your classes:
12.  

    How did you hear about Access Services?

    Counseling Center

    Family Member

    High School

    Professor

    Vocational Rehabilitation

    Other (Specify Below)

    Additional Note or Comment
13.  

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

    Yes

    No

    Additional Note or Comment