Disability Support Services Application

Disability Support Services Application
Please complete this application to request accommodations. If you need assistance with this form, please contact Vanessa Williams at 870.875.7235 or email her at VWilliams@southark.edu.
Student ID#*
Type in your SouthArk ID number.
Name*
School E-Mail Address*
example@southark.edu
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone #
Preferred phone number
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone #*
Please enter a valid phone number.
Year*
Semester accommodations are needed:*
Choose the semester for which you are requesting accommodations.
Major*
Desired Accommodations*

Extended time on exams/quizzes (time & 1/2)Testing in a quiet environmentTape record lectures with digital recorderSeating in frontSeating by doorBrief breaks (5-10 minutes)Proctored ExamReligious Exemption (Additional documentation for this accommodation will be required after submitting this application)Other (if enlarged font, specify size)
Student Comments:
Your application will not be processed until all documentation of a disabling condition is received. If you do not have your documentation at this time, do not submit this application. The documentation must be official company stock (i.e. letterhead) and can include medical, psychological, or educational records. You are encouraged to ask your treating medical professional to provide you with a letter listing appropriate accommodations relative to your condition.

Medical Documentation, Educational Documentation, Secondary School IEP/504 Plan, Psychological/Intelligence Assessment Reports
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Upload your class schedule and a picture of your student identification card here. *

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Students are encouraged to submit requests for accommodations as soon as possible since some accommodations take longer to arrange.

By submitting this form, you understand and agree that:
1. If you are allowed to tape-record lectures, the recordings are for use in personal studies only. Recorded lectures may not be shared with other people without the written consent of the lecturer. You are also aware that the information contained in the tape-recorded lectures is protected under federal copyright laws and may not be published or quoted without the expressed consent of the lecturer and without giving proper identity and credit to the lecturer.
2. Instructor notes or other materials supplied to you as an accommodation are not to be shared with others.
3. If you do not return equipment loaned from the DSS office, you will be charged for its replacement at current market prices. A hold may be placed on your account until the equipment is returned or a replacement fee has been paid.
4. If cell phones, tablets, and other electronic devices are permitted as assistive devices, DSS only authorizes their use as an assistive device during classes or other required course activities. Other use during classes or course activities is at the instructor's sole discretion.
5. If you disagree with the accommodations given to you, you will schedule an appointment with the DSS office to discuss alternatives within 7 days of the "faculty notification" email notice sent to your SouthArk email.
6. The SouthArk email address is the only email officially recognized by the DSS office after students have been admitted to SouthArk and issued a SouthArk email. Correspondence to personal email addresses is made as a courtesy and may not always reach students due to security measures.
7. If the accommodations given to you are not honored by instructors, you will notify the DSS office immediately.
8. You will abide by these guidelines while enrolled at South Arkansas College.
For Office Use Only
For Office Use Only. Reason for denial if applicable:
Should be Empty:

Disability Support Services Application

Please complete this application to request accommodations. If you need assistance with this form, please contact Vanessa Williams at 870.875.7235 or email her at VWilliams@southark.edu.