105 B. J. Albritton Drive Jacksonville, Texas 75766-4659
903-586-2518
Accommodations Request and Consent Form
Application for Accommodation(s)
Name (Last, First, Middle)
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Date of Application
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Month
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Day
Year
Date
Email
example@example.com
Mailing Address
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Telephone Numbers (Home and Cell)
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Date of Birth
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Month
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Day
Year
Date
Other College and Universities Attended (and dates)
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Accommodations requested
Type of Disability
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I am requesting the following as accommodations inside and/or outside of the classroom:
Extra Time on Tests (up to 1.5x scheduled time)
Testing in a Quiet Location
Oral Tests
Copy of Class Notes
Preferential Seating
Use a Laptop in Class
Emotional Support Animal in Campus Housing
Counselor Information: If you are a client of a rehabilitation agency please list below the name, phone number, and mailing address.
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Medical/Diagnostician Information: Please list below the name, phone number, mailing address of your physician/diagnostician.
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Please upload your medical/diagnostic evaluation reports with this application that provides evidence of your disability and its limitations to your mobility or academic performance. These records must be current (3 years maximum).
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Your request must be approved in consultation with the Office of Student Wellness. You may meet at any time to request changes to any of your approved accommodations. Initial accommodations can begin only when you submit the Instructor's Notification of Disability Accommodation form to your instructor. Accommodations can not be retroactive.
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Please check the box if you understand the above statement.
Consent and Submit
I have read and understand the information on the accommodation request form. I agree to comply with the procedures and stipulations. I certify that the information I have provided is accurate and true and may be shared with the appropriate member. I understand that the faculty and staff of Jacksonville College may need to share information regarding my learning and instructional needs. I give them permission to discuss those needs in the course of their assigned responsibilities in order that they may provide me with assistance I need to pursue my academic goals. If you clicked yes, please sign electronically.
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Yes, I agree
No, I do not agree
Signature of Student
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Submit
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