Jacksonville College 903-586-2518 105 B. J. Albritton Drive Jacksonville, Texas 75766-4659
504 Introduction and Protocol Form
Access to education means more than simple admission to a college. Access means providing students with the tools they will need to be successful in higher education. Students with an identified disability should be no exception. In fact, Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 insures that all qualified persons have equal access to education regardless of the presence of any disability. Reasonable accommodations based on the disability of each student is the way to ensure access for the student with a disability. Jacksonville College wants to provide equal access to all students expressing an interest in attending college here. Every student who is qualified (meets requirements that all students are required to meet) can attend Jacksonville College whether they have a disability or not. It is the student’s responsibility to identify himself/herself to the appropriate school official and provide documentation of a disability. Strict documentation guidelines exist for different types of disabilities and require a current diagnosis, prognosis, and explanation of how the disability may impact the student’s academic performance. The student should contact the Dean of Students who will determine appropriate accommodations, and, after reviewing documentation prepared by a licensed professional, will contact the student to discuss the impact the disability may have on his/her academic success. There must be a direct connection between the functional impact of one’s disability and the accommodation that is approved. The student will sign a “release of confidentiality form.” This form gives permission for the Dean of Students to discuss educational needs with college personnel who may have an academic interest in that student. Once all of the paperwork has been received and accommodation suggestions made, the student will send a digital form titled "the instructor notification form" to their instructor. The student and instructor will review the accommodations and discuss a plan for implementation.
Steps to Receive 504 Services
The student must complete the application for disability accommodations. The student must complete a release of confidentiality form. The student must submit copies of supporting documentation (psyc eval, 504 records, etc.). The student must submit all of the above to the Dean of Students. The student must contact the Dean of Students to discuss accommodations and fill out the accommodations form. The student with the help of the Dean of Students will have each instructor sign the form in acknowledgement, and once completed return the accommodation form. The Dean of Students will make a digital copy of the form for the student and each instructor indicated on the form. Once each instructor has received the signed copy of the form they become obligated to give accommodations. No instructor is obligated to provide accommodations until they have the completed form in their possession. If a student has an obvious disability, the instructor can provide accommodations while the process is being completed.
Application for Disability Accommodation
Part 1: General Information
Name (Last, First, Middle)
Date of Application
Telephone numbers (Home and Cell)
Date of Birth
Other College and Universities attended (and dates)
Type of Disability
Counselor Information: If you are a client of a rehabilitation agency please list below the name, phone number, and mailing address.
Medical/Diagnostician Information: Please list below the name, phone number, mailing address of your physician/diagnostician.
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).
Drag and drop files here
Choose a file
Your request must be approved in consultation with the Dean of Students. You may meet with the director 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.
Please check the box if you understand the above statement.
Part III: Accommodation Request Note: The Dean of Students cannot inform instructors about a student’s disability. If you wish instructors to provide accommodations for your disability needs, you must complete this form and then use the “Instructor’s Notification of Disability Accommodation” form. Instructors will be requested to keep all information confidential.
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.
Yes, I agree
No, I do not agree
Signature of Student
Want More Information?
If you would like more detailed information go to your Moodle account, click on your courses, and you should have access to 504 Accommodations.
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