Public Accommodation Request

Student Information

Please enter your information

First Name

Last Name

Middle Name

Student ID

Email

Please only use your Charter Oak State College email address

Phone Number

Date of Birth

Specific Accommodation Information

What is your diagnosed disability?

My diagnosed disability falls into the following category

How does your disability affect you academically?

How does your disability affect student life on campus, outside academics?

What accommodations have you used in the past?

What is your current status?

What is the best way to get in contact with you?

Documentation

Students should have their medical/clinical provider fill out the “Medical Provider Documentation”. A typed written report or psychological/educational evaluations from the appropriate medical/therapeutic professional may accompany the Medical Provider Documentation form if necessary.

Please Review the Medical Documentation Guidelines before submitting your request

Upload supporting document(s)

Consent for Release of Information

I consent to and request all appropriate persons and/or agencies or institutions to release information regarding myself to Charter Oak State College for use in education planning. All information will be kept confidential and maintained as part of my records with the Office of Accessibility Services. I authorize the release of my medical, counseling, or disability records to the Office of Accessibility Services. I also authorize Sarah Ellis, Coordinator of Accessibility Services and/or Wanda Warshauer, Director of Academic Services, and/or David Ferreira, Provost and Vice President of Academic Affairs to seek further information from my documentation provider to clarify requested accommodations and to engage in the interactive process as required by the ADA.

Agreement to Release of information

Public Accommodation Request

Student Information

Specific Accommodation Information

Documentation

Consent for Release of Information

Document Information