Application for Accommodation for Disability Listen Applicant Name * Required First Last Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone * RequiredEmail * Required Birth Date * Required MM slash DD slash YYYY Student ID Program Major * Required Month & Year entering Program * Required Describe your disability * RequiredWhat are your requested accommodation(s), including any equipment, aids or services * RequiredIf you are working with other agencies, please list them and a contact person if know (i.e. Department of Vocational Rehabilitation Services)Please submit current professional evidence documenting your disability, such documentation must verify the specific accommodation requested. Drop files here or Select files Max. file size: 256 MB. Please review the accommodation acknowledgements and check all. * Required I am requesting accommodations to compensate for my disability and to assist me in meeting educational requirements. I give permission to discuss my accommodation information with Northwest Iowa Community College professors, administration, and necessary staff person to establish accommodation procedures. This is for educational purposes only. Northwest Iowa Community College has my permission to contact my previous disability services or education provider(s) for information relative to accommodating my educational needs. I understand that acceptable documentation of my disability must be on file before an accommodation can be made and that the documentation MUST VERIFY YOUR NEED FOR THE REQUESTED SUPPORT. Applicant Signature * Required Reset signature Signature locked. Reset to sign again A meeting with the Accommodations Office should be scheduled at your earliest convenience as the next step in your process. CAPTCHA
