Accommodation Request

Student Information

Please enter your information

First Name

Last Name

Middle Name

Student ID

If you are a prospective student please enter "Prospective Student"

Email

Please use your university issued email address

If you are a prospective student please enter your personal email address

Phone Number

Date of birth

Are you a Veteran?

What is your diagnosed disability/diagnosis?

Describe your disability/diagnosis and how it affects your performance as a student inside the classroom

What Accommodations Would You Like To Request?

Please select all accommodations that you would like to request.

Students are allowed to request more than one accommodation.

If other, please specify what additional accommodations you would like to receive:

Where would you like to use your Accommodations

Did you receive accommodations from any other college or university?

How did you hear about Student Access and Accommodation Services at Heartland Community College?

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