CONFIDENTIAL

To: Dean of Student Services, Flint Hills Technical College

Last Name:
Middle:
First Name:
Email:
Address:
Address2:
City:
State:
Zip:
County:
Home Phone:
Work Telephone:
IDENTIFY NATURE OF REQUIRED SERVICE OR ACCOMMODATION
Testing accommodation, if requested in a timely manner:
Academic support services:
Auxiliary aids:
Other:
I verify that the information submitted in this form is true and accurate:
Signature (please type your name):
Date:	Now

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.

Rev 07/012002