Attention: If you do NOT have a disability, do NOT fill out this form! According to the Americans with Disabilities Act of 1990, the term "disability" means, with respect to an individual: A physical or mental impairment that substantially limits one or more of the major life activities of such an individual; A record of such an impairment; or Being regarded as having such an impairment. In order to most effectively meet the needs of its students with disabilities, the Disability Support Services Office at CCBC is requesting that students with disabilities complete this form. Completion of this form is purely voluntary. Requests for accommodations must be completed each semester. If you change your schedule you must complete a new form or contact your DSS Counselor. Your contact information Name * Address City State Zip code Telephone Select the location(s) you will be taking face-to-face classes this semester Campus CatonsvilleHunt ValleyDundalkOwings MillsEssexRandallstownOn which campus will you be taking face-to-face classes this semester? Please check all that apply. Semester WinterSummerSpringFall Year Email CCBC ID # ex.900-123-456 * Date MonthDayYear Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Name of DSS counselor Approved accommodations by your DSS counselor Accommodations Please indicate the accommodations that have been approved by your DSS counselor (to be verified). Accommodation letters YES. Please prepare letters for me to deliver to my instructors.NO. I will not need accommodation letters at this time.Instructors must be notified by accommodation letter if you plan to use accommodations. Students are responsible for picking up accommodation letters and delivering them to instructors. Comments List courses including CRN#, Subject, Course#, Section, Day(s),Time, Campus Course Registration Be sure to include CRN#, Subject, Course#, Section, Day(s),Time, and Campus. **Students are responsible for picking up letter and delivering to instructor.