Disability Services Request Form

Johnston Community College
P.O. Box 2350
Smithfield, NC 27577
Wilson Bldg., Room 1214
919-209-2120
TTY 919-209-2154

Federal Law prohibits Disability Services from making pre-admission inquiries about disabilities. The Disability Services Office has been designated on campus to assist students with disabilities. In order to provide this assistance it is necessary for students with disabilities to identify themselves in a timely manner. Please remember that any information you provide is strictly voluntary and will be kept confidential.

In order to facilitate your learning experience at Johnston Community College, we ask for you to complete the following information and return this form along with proper disability documentation to the Disability Services Coordinator.

Please complete the following:

If you prefer, you may fill out and print the paper form here and return to the Disabilities Services Coordinator in Wilson Building, Room C1041A.

Name: __________________________________________________ SS#: ____________________
                  (Last Name, First Name, Middle Initial)

Address: __________________________________________________________________________
                     Street/P.O. Box City State Zip Code

Home Phone: _____________ Work Phone: _______________ Cell Phone: ________________

Date of Birth: _____________ *Sex: ____ Male ____ Female  *Ethnicity: ___________________

Email Address: _____________________________ Program of Study: _____________________

Have you requested Disability Services in the past? ____ Yes ____ No

If so, when? _________________________

* For statistical purposes only

Please answer by checking the appropriate response:

Do you have a disability that substantially limits one or more major life activities? ____ Yes ____ No

What is the nature of the disability? (Check all that apply)

___ Deafness	___ Hard of Hearing
___ Blindness	___ Visual Impairment
___ Mobility Impairment	___ Learning Disability
___ Traumatic Brain Injury	___ Attention Deficit Disorder
___ Medical	___ Psychiatric
___ Temporary	___ Other: _______________

What major life activity is involved? (Check all that apply)

___ Reading	___ Writing
___ Talking/Speech	___ Walking
___ Math	___ Climbing stairs
___ Physical activities	___ Other: ______________

How does this disability affect you in an educational setting?

______________________________________________________________________________________________

Please read and sign below:

• It is the student’s responsibility to make a disability known and to provide proper documentation from an appropriate professional describing a diagnosis, limitations, and recommended academic adjustments and/or auxiliary aids.
• It is the student’s responsibility to request services in advance each semester.
• It is the student’s responsibility to keep instructors and Disability Services informed of implementation and effectiveness of an academic adjustment and/or auxiliary aid.
• The student understands that academic adjustments and/or auxiliary aids are not automatically granted.
• Students registered with Disability Services must adhere to student behavior guidelines outlined in the Johnston Community College Student Handbook.

My signature below certifies that the information provided is accurate and acknowledges that I am fully aware of my responsibilities as it relates to my Request for Disability Services. My failure to follow these guidelines may result in a delay or interruption of services.

_________________________________________    ______________________________
Student’s Signature                                                        Date

 

_________________________________________    ______________________________
Parent/Guardian Signature for minors (under age of 18)   Date

Please return this completed form along with supportive documentation to:

Disability Services Coordinator
Johnston Community College
P.O. Box 2350
Smithfield, NC 27577

Johnston Community College is committed to equality of educational opportunity and does not discriminate against applicants, students, or employers based on race, color, national origin, religion, sex, or disability.