Voluntary Disclosure

VOLUNTARY DISCLOSURE OF A DISABILITY

Attention: This form is used only for disclosure of a disability. If you do not have a learning disability, you do not need to fill out this form.

Qualified individuals are entitled to reasonable accommodations under the Americans with Disabilities Act (ADA regulations). Accommodations are determined on a case-by-case basis. Learning Support Services serves as links between individuals with disabilities and the campus community. Information released will provide documentation of a disability for faculty, staff, students, and prospective students of Hartwick College. All information will be considered confidential and will be released only to appropriate personnel on a need-to-know basis. To access services, individuals must initiate a request in writing for specific services/accommodations (alternative text format, enlargements, interpreters, etc.). Accommodations prescribed apply only to Hartwick College and may not be valid elsewhere. The individual student takes full responsibility for ongoing assistance. In order to receive services/accommodations, verification of a disability is required.

*FIRST Name:
Middle Name/Initial:
*LAST Name:
*Student ID Number:
*Address:
*City:
*State: *Zip Code:
*Country:
*Phone Number:
*Hartwick E-mail Address: @hartwick.edu
*Non-Hartwick E-Mail Address:

*Nature of disability: Learning Physical Psychological
Please describe your disability:

*In the past, have you required any classroom accommodations? Yes No
If yes, check all that apply:

Extended time on exams Lecture notes Reader for exams
Scribe for exams Spelling waived Word processor for exams
Audio books Foreign language exemption Other:

 

What classroom accommodations will you be requesting?

Extended time on exams Lecture notes Reader for exams
Scribe for exams Spelling waived Word processor for exams
Audio books Other:
Note: Hartwick does not exempt students from foreign language requirement.

*Will you be submitting documentation to verify your disability? Yes No

I understand that the review process may take up to two weeks and that I may call or e-mail the Disability Services Office to find out the status of the review. I give permission to the Coordinator of Disability Services to release information about my disability/progress to my instructors, advisor(s), and other appropriate personnel on a need-to-know basis only.

Sign electronically by typing your name and the date:
*Name: *Date: