FOR DISABILITY SERVICES
The purpose of this form is to give you, the student, the opportunity to tell SDS about your disability, the impact of the condition, what accommodations you have used in the past, and the accommodations that you will need at CCC to address this impact.† We strongly encourage you to submit this request and documentation before the start of your classes - doing so will facilitate the timely provision of accommodations approved by SDS.†
† To be eligible for accommodations and disability services, you must do the following:
1. †Submit this Request for Disability Services Form
2. Submit current and comprehensive disability documentation.† Documentation guidelines and forms are available from the SDS main office (962-9262) and our website: www.corning-cc.edu/future/sds
3. Meet with a SDS staff person for an initial intake interview.†
The student should complete this form whenever possible. If student is unable to complete, please notify SDS staff.†
Name:_____________________________________†† †††C ID: __________________†† Date of Birth:__________________†††
Address:____________________________________________ City, State, Zip__________________________________
Home Phone Number:________________________________† Cell Phone Number:______________________________
Email:___________________________________ How did you hear of Student Disability Services? ________________
High School Graduation Year___________†††††††† Type of Diploma (Please Circle):††††† Regent†† Local††††† IEP† ††† GED†† †† None
Are you a veteran?† ___________________________†††††††† CCC Major:_________________________________________†
New or Continuing Student (Please Circle)††††††††† Subjects/Courses giving you trouble____________________________
How confident do you feel about the following skills?† 1=Not Confident†† 2=Somewhat Confident†† 3=Confident
____ I understand my disability.
____ I can explain to teachers and staff how my disability affects me in the classroom.†††††
____I know what accommodations Iíve used in the past and can explain how they helped me.†††
____I feel comfortable approaching my instructors and discussing my accommodations.†††
____If a professor did not want me to use my accommodations I would know what to do.
†____I can follow procedures to use my accommodations.
____If I am having a problem, I know who to go to for help.†
Do you use any assistive technology (ie: Dragon, Kurzweil, Smart Pen)?______________________________________________
Are you interested in assistive technology training(Assistive Technology is technology used to help complete school work)?_____
What was/is your disability and when was it first identified? ___________________________________________________________________________________________________
To the best of your ability, please describe your disability.† †____________________________________________________________________________________________________________________________________________________________________________________________________
In your own words, please describe how your disability affects you in the classroom.†
Describe any previous disability accommodations and services you received in an academic setting, such as High School.
What accommodations are you requesting to use at CCC?
Describe any auxiliary aids, assistive technology, and/or services you may need while attending CCC, if applicable (e.g. FM system, wheelchair, books in audio/alternative format, etc.).
What are your strengths?
With what do you need the most help? ______________________________________________________________________________________________________________________________________________________________________________________________________
Anything else you would like us to know? ______________________________________________________________________________________________________________________________________________________________________________________________________
Student Signature††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† ††††††††††††††† Date
Mail or submit this form to:
Corning Community College
Student Disability Services
1 Academic Drive
Corning, NY† 14830