Student Accommodation Request

Student Information

Completing this form is the first step in the interactive three step accommodations request process.

The college student is required to complete this form. While other individuals may assist (such parents, advocates, etc.), it is the student’s responsibility to complete the form and to ensure the information shared is accurate.

Complete all fields to the best of your ability. It should take approximately 5-10 minutes.

Once the form is completed, you will receive information regarding required supporting documentation and how to submit it or you can opt to submit it with this form.

First Name

Preferred First Name

Last Name

Date of Birth

Student ID

Student CCSNH Email

Use your CCSNH issued email address.

Phone Number

Preferred Pronouns

Select your home college (where applied / accepted into a program)

Are you an Early College Student?

Disability Information

I have a documented disability in the following area(s):

If other, please specify

Temporary Impairment

If other temporary impairment, please specify

Accommodation Information

What accommodations have you benefited from in the past? What else might be helpful?

Is there other information that you think would be helpful for the Accessibility Coordinator to know?

Documentation

Please click on “Add Item” below to upload any documentation to support the request for your accommodations. Documentation is required in order to initiate the process of receiving accommodations with ASO. For more information on documentation requirements, please visit our website: Guidelines for Documentation of a Disability - Community College System of New Hampshire

College Specific Information

Are you a student athlete at GBCC or NHTI?

Are you a student at LRCC or NHTI requesting accommodations for:

Accessibility Services Permission to Release and Exchange Information

In order to speak with individuals outside of CCSNH, complete the release of information form specific to Accessibility Services.

I give Accessibility Services permission to discuss pertinent educational, psychological, and/or medical records for the purpose of providing accessibility/disability support services at my home CCSNH college or colleges I am registered for a course during a specific term. This includes contact by e-mail, fax, telephone, and in-person.

I am 18 years old and my own legal guardian

Accessibility Services may release/exchange information with the individuals listed below:

For each contact, please list the person's name, relationship or agency, and contact information. Note: You can include parents, siblings, significant others, doctors, counselors, Voc Rehab counselors, etc. Example: Sue Peterson, Mother, phone 000-000-0001

Signature

I understand and agree that the release is in effective until Accessibility Services has received written notice to revoke permissions to a specific person/institution, etc.

You can revise Accessibility Services Permission to Release and Exchange Information form at any time by submitting an updated, signed form.

Signature Date

Confirmation

I acknowledge that submitting this form does NOT complete the accommodation process

Completing this form is only Step 1 of the interactive accommodation process and does not guarantee eligibility for accommodations. The interactive accommodation process includes 3 Key Steps:

Register with Accessibility Services (this form starts the process)
Submit documentation
Meet with Accessibility Services at your home college

Students need to complete all 3 steps to complete the accommodation process. If you have any questions about completing the accommodation process, please follow-up directly with Accessibility Services at your home college.

I hereby confirm that I have completed this form myself and submit it for review:

Please type your name below.