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
*



Select the location(s) you will be taking face-to-face classes this semester
Campus


On which campus will you be taking face-to-face classes this semester? Please check all that apply.


Semester






ex.900-123-456

*





Approved accommodations by your DSS counselor
Please indicate the accommodations that have been approved by your DSS counselor (to be verified).



Accommodation letters


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.






List courses including CRN#, Subject, Course#, Section, Day(s),Time, Campus
Be sure to include CRN#, Subject, Course#, Section, Day(s),Time, and Campus.