Disability Accommodation Request

Cecil College Student Information

Student ID Number

If you have not been assigned a Cecil ID, please enter your birth date in the following format: MM/DD/YYYY.

First Name

Last Name

Middle Name

Preferred/Chosen Name

Date of Birth

Gender

Pronouns

Example: he/him, she/her, they/them, etc.

Expected Graduation Term

Enter the semester and year you plan to graduate (best estimates are fine)

Student Contact Information

Student Cell Phone Number

Cecil Email

If you have not been assigned a Cecil email, please enter your personal email. Note that this will be overwritten as soon as you are assigned a Cecil email.

Email Format: yourinfo@chawk.cecil.edu

Emergency Contact Information

Emergency Contact's Name

Emergency Contact's Phone Number

What is your emergency contacts relationship to you?

Accommodation Request Details

My diagnosed disability falls into the following category

Select all that apply

How does your disability impact you in educational environments?

(In class, during exams, reading/writing, group work, etc.)

What accommodations are you requesting?

What accommodations have you received in the past, if any?

Example: In K-12 as part of an IEP or 504 plan; From another college or university previously attended.

Will you need accommodations for the Math or English Skills Assessments?

When do you plan to start using accommodations?

Enter the semester and year you would like to start using services.

Additional Questions:

Are you part of the Early College Academy, or dually enrolled in high school and at Cecil College?

Cecil College provides a variety of services to help you become/remain a successful student.

Which of the following would you like to learn more about? (select all that apply).

Are you attaching documentation with this application?