Student Access Office Registration Form

Student Access Office (SAO) Registration Form

Qualified individuals with a documented disability may request reasonable accommodations. To do so, the following must be completed, signed and submitted to the Student Access Office: (1) this Student Access Office Registration Form, (2) the signed Consent and Release of Academic and Disability Related Information Form, and (3)supporting copies of current (one year or less) disability documentation from a federal or state licensed medical professional, including licensed mental health professional.
When a Registration Form is completed and submitted, the Student Access Office will contact the student in a reasonable period of time.
If accepted, an appointment and review of reasonable accommodations will be made.

Name*

First Last

Address*

Street Address Address Line 2 City State ZIP Code

Home Phone

Cell Phone*

Email*

Student ID#*

When was your disability or chronic illness first diagnosed?*

Are you registered with ACCES-VR (Adult and Career and Continuing Education Services- Vocational Rehabilitation), the NYS agency formally known as VESID?*

YES
NO

Supplemental Supporting Documents Upload*

(Not ONLY IEP, but other disability documentation such as Psycho-educational Evaluation, etc.)

Drop files here or

Max. file size: 50 MB.

Services Requested:*

Assistive Devices
Extended Test Time
Quiet Separate Testing Location
Preferred Seating
Use of assistive listening devices
Enlarged print for class notes and other materials
Other

Please specify:*

FOR TRANSFER STUDENTS:

Please list any reasonable accommodations that you received from any/all other colleges:

College:

Accommodations Received:

Acknowledgment of Student Access Office Registration Form:*

I, the undersigned, have read, understand, acknowledge and verify the truthfulness of the contents of this SAO Registration Form and agree to the terms of the Student Access Office Registration Form and process. Further, to the extent that provisions and guidelines of the FTC Student Handbook and/or Residence Life Handbook relate herein, I acknowledge that.

Section 504 & the ADA allow colleges to require documentation of a disability in order to determine the most appropriate reasonable accommodations that a student will need. The FTC Student Access Office holds all documentation in the strictest confidence and will not release specific information without authorization from the student. Guidelines for documentation are available upon further request.

Note: Please allow a reasonable amount of time for Student Access to review the Registration Form and documentation. Please note that while there are generally no additional costs, there may, on occasion, on a case-by-case basis be an additional cost depending on the extent of the needs of the applicant. Also, all provisions of the institution’s policies and guidelines apply to any/all qualified individuals who accept the accommodations.

Consent & Release of Academic and Disability Related Information

Student's Name*

First Last

Student ID Number*

I hereby consent and permit Five Towns College to release my student information to the following person(s):

Name*

Relationship*

Contact Numer*

Name

Relationship

Contact Numer

Signature*

I, the undersigned, have read, understand, acknowledge and verify the truthfulness of the contents of this SAO Registration Form and agree to the terms of the Student Access Office Registration Form and process. Further, to the extent that provisions and guidelines of the FTC Student Handbook and/or Residence Life Handbook relate herein, I acknowledge that. Further, to the extent that it is necessary, I consent and permit the Student Access Office permission to contact my professors and/or other College staff regarding my need for reasonable accommodations and concerns that may affect my academic success. I also understand that I have the right to cancel my permission to release information at any time before it is released.

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Date