CONFIDENTIAL

To: Dean of Student Services, Flint Hills Technical College

Last Name:
Middle Name:
First Name:
Social Security Number:
Permanent Address Information:
Address 1:
Address 2:
City:
State:
Zip:
County:
Home Phone:	() -Second partThird part
Work Phone:	() -Second partThird part
Local Address Information (if different than above):
Address 1:
Address 2:
City:
State:
Zip Code:
County:
Home Phone:	() -Second partThird part
Work Phone:	() -Second partThird part
Course of Study:	Automotive Technology Business Administrative Technology Computer Program Design & Development Construction Technology Dental Assisting Dental Hygiene Emergency Medical Technician Graphic Arts Technology Health Occupations Technology Hospitality/Culinary Arts Industrial Engineering Technology Machine Tool Technology Network Technology Paramedic Power Plant Technology Practical Nursing
Disability Information:

Disability is: Temporary     Permanent
Disability Category:
Vision:	Description:
Mobility/Ortho:	Description:
Hearing:	Description:
Learning Disabiltiy:	Description:
Speech:	Description:
Other:	Description:

Verification:
I verify that the information submitted in this form is true and accurate:
Signature (please type your name):
Date:	Date and timeNow

 
IT IS THE RESPONSIBILITY OF THE INDIVIDUAL STUDENT TO REQUEST ACCOMMODATION OR AUXILIARY AIDS AT LEAST SIX (6) WEEKS BEFORE CLASSES, PROGRAMS, OR ACTIVITIES BEGIN.

AVAILABILITY OF AUXILIARY AIDS

IT IS THE STUDENT’S RESPONSIBILITY TO MAKE WRITTEN REQUEST FOR ASSISTANCE IN OBTAINING SPECIALIZED SUPPORT SERVICES FROM OTHER RESOURCES such as State Vocational Rehabilitation, Recordings for the Blind, State Services for the Blind, etc. For example, the Division of Vocational Rehabilitation (DVR) may fund such items as transportation to the institution, tuition, text books, hearing aids, and other individually pre-scribed devices.