Accommodations Request/Inquiry Form

Name(Required)

Preferred Pronouns(Required)

Please enter your preferred pronouns. Some examples are she/her/hers, they/them/theirs. he/him his.

Date of Birth

Email(Required)

Phone(Required)

YCCC Student ID # (if known)

I am…(Required)

The best way to reach me is…(Required)

I am requesting accommodations because…(Required)

I have a documented disability.

I think I have a disability but I don’t have documentation and/or a diagnosis

I have a temporary disability.

I am not sure, but I have questions.

The disability that impacts/may impact my ability to access courses at YCCC is…(Required)

Have you previously received accommodations either at work or at school? If so, what were they and how did they help or not help?

What barriers have you experienced or do you anticipate experiencing in your classes at YCCC?

There are many resources both on and off campus that students utilize to increase their academic success. Examples include family, friends, psychologists, academic resource centers, individual tutors, etc. What are some of the resources available to you that you plan on accessing while studying at YCCC?(Required)

Early College

Vocational Rehabilitation

Student Success Commons

Case Management

Individual Tutor(s)

Other

If you have documentation of your disability and are ready to submit it, you may do so here. This is NOT required at this time. Accommodations are not retroactive and can take up to two weeks to process; they will begin only after a student has completed the steps necessary for approval.

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Max. file size: 64 MB.

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Accommodations Request/Inquiry Form

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