Request Form for Disability Services

*First Name:

(required)

Middle Initial:

*Last Name:

(required)

*Personal Email:

(required)

Cowley Email:

Home Phone:

Cell Number:

Work Number:

Address:

City:

State:

Zip:

Campus Location:

Are you enrolled in the IMPACT program? Yes No

Do you receive assistance from Vocational Rehabilitation? (SRS)? Yes No

If yes, who is your counselor?

Disability: (Check all that apply)

Acquired Brain Injury

Learning Disabilities

Chemical Dependence

ADD/ADHD

Orthopedic/Physical Disability

Temporary Disability

Blind

Psychiatric Disability

Deaf

Partial Sight/low vision

Medical Disability

Speech Disability

Hard-of-Hearing

Other (Explain)

Accommodations: (Check the accommodations you feel would benefit you in classes at Cowley. Accommodation approval is based on supporting documentation of the disability.)

Extended test time

Test in distraction reduced site

Test read to me

Note taker

Record Lectures

Assistive Technology Software

Textbook in alternate format

Calculator

Enlarge Print Material/Handouts

Interpreter (Sign)

Closed Caption Video

Preferred seating

Scribe

Listening Device

Other Accommodation?

This Program Application, along with current documentation, should be forwarded to the Disability Services Office at Cowley College. It is important that students who are planning to request accommodations submit their documentation to the Disability Services office as soon as possible. Services are gladly provided to qualified applicants on a first-come first-serve basis; however, we can not be held responsible to provide a service when the resource available is limited or no longer available. Though we shall make every attempt to provide qualified applicants with appropriate accommodations, as available, it is incumbent upon the student to apply for services as soon as possible.

Submit documentation to:

Jim Brown, Student Accessibility Coordinator
125 S. Second St. P.O. Box 1147
Webb Brown Room 202
Arkansas City, Kansas 67005

Release of Information forms are available in the Disability Services Office or click here to view a PDF copy.

I understand that this form does not constitute an agreement for services.
I understand that this form is merely an application which requests admittance to the program.
I understand that I must contact the Disability Services Coordinator to schedule accommodations for course placement assessments and that this must be done prior to the scheduled assessment date.
I understand that my disability documentation must be updated every three years. This may require re-evaluation at my own expense.
I understand the Disability Services Coordinator may contact my instructors at any time regarding the accommodations and academic progress.
I understand that I MUST submit a copy of my disability documentation to the Cowley College Disability Services Office before I can receive any accommodations.
I understand that I MUST schedule an appointment with the Disability Services Coordinator to complete a Personalized Plan of Assistance and request my accommodations.
620.441.5557.

Disabilities Services

Request For Service