Fall 2015
SHELTON STATE COMMUNITY COLLEGE
Office of Disabilities Services Application
General Information
Please print.
Name: ________________________________________________________ Male: _____ Female:______
Student Number:_______________________________________ Age:_______ DOB: _______________
Local Address: ________________________________________________________________________
City:_________________________________ State: ______ Zip:_________________________________
Phone (cell or home with area code)_______________________________________________________
Do you receive text messages?
____Yes
____ No
Email Address: ________________________________________________________________________
Parent/Guardian Name(s):_______________________________________________________________
Anticipated Major: _____________________________________________________________________
Academic Advisor: _____________________________SOAR Advisor: ____________________________
High School attended: _______________________________________Year completed: ______________
Resources for college payment:
___ Parents/Self
___ Vocational Rehab
___ Pell Grant/Fin Aid
___Scholarship/Other
Name: _______________________________________________________________________________
Agency: ______________________________________________________________________________
Type of Disability:
__Attention Deficit Disorder (ADD)
__Attention Deficit/Hyperactivity Disorder (ADHD)
__Brain/ Head Injury
__Psychiatric /Psychological Disorder
__ Specific Learning Disability (Please describe.) _____________________________________________
__ Physical Impairment _________________________________________________________________
__ Other (Please describe.) ______________________________________________________________
Fall 2015
Please describe your disability. Include diagnosis as well as cause and date of onset (if known). List past
accommodations that have worked for you.
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
What strategies or services do you use on a regular basis to help compensate for your disability?
_____________________________________________________________________________________
_____________________________________________________________________________________
COLLABORATION WITH OTHERS:
To assist with arranging reasonable and appropriate accommodations, it may be necessary on occasion
for ODS personnel to communicate with other people involved in your education. Your signature below
allows the employees to communicate with others to provide the best reasonable academic
adjustments. This will occur only on an AS NEEDED BASIS.
I give permission for the ODS staff to share information with the following people:
___Members of the SSCC faculty/staff regarding ODS recommended accommodations affecting my
course work and academic performance or assist in providing the requested accommodations.
___Other individuals or agencies listed below:
___ Vocational Rehab Services Counselors ____________________________________________
___ Academic Counselor/Navigator__________________________________________________
___ Referring instructor or counselor_________________________________________________
___ Mother (list by name) _________________________________________________________
___ Father (listed by name) ________________________________________________________
___ Spouse/Other________________________________________________________________
___ ____________________________________________________________________________
I certify the information on this application is accurate and complete to the best of my knowledge. I
hereby authorize Shelton State Community College to obtain information from my educational record
pertinent to my participation in the program. (i.e. high school and college transcripts, entrance test
scores, and semester and cumulative grades)
Signature: _______________________________________ Date: __________________ ODS: _________
Applying for services beginning:
Spring / Summer / Fall
Year: _______