Confidential Registration Form

If you have questions or concerns please call or email the Accommodative and Accessibility Services Office at 315-786-2335 or accommodations@sunyjefferson.edu.

* indicates a required field

Student Information

Under Section 504 of the Rehabilitation Act, the Americans with Disabilities Act (and all amendments) and the NYS Human Rights Law, Jefferson Community College is mandated to make reasonable accommodations for otherwise qualified students with disabilities. Accommodations are determined on a case-by-case basis by the Disability Specialist.

To receive accommodations/services, qualifying documentation of a disability is required. To access accommodations/services, individuals must initiate a request (as outlined below) for specific accommodations/services. The earlier individuals request accommodations/services, the more effective the College can be in facilitating the appropriate support.

Accommodations are not retroactive; it is best to request accommodations before a problem arises.

Requesting accommodations does not guarantee their approval. Final determination will be made by the Disability Specialist and based upon the documentation received.

Students with disabilities are ensured that written records will be kept confidential and made available only to the Education Coordinator and/or designee. The Family Educational Rights and Privacy Act (FERPA) of 1974 and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) protect the confidentiality of student medical and disability records. Once submitted, disability-related information becomes the property of Jefferson Community College and is kept in separate files with limited access. FERPA protects a student's record from being shared (without the student's permission) with faculty, administrators, other students, the press, or anyone without a legitimate, educational reason. The student must complete an Accommodative Services Release form.  If consent is given by the student, only the diagnosis will be shared, not the documentation. In order for parents or legal guardians to speak with the Education Coordinator regarding any information on the student (grades, services, attendance, documentation needs, etc.); the student must complete a release of information form.

Legal First NameRequired *

Legal Last NameRequired *

Chosen Name

J NumberRequired *

JCC EmailRequired *

Cell Phone NumberRequired *

Home Phone Number

Preferred Pronouns

Emergency Contact Name

Relationship to you

Emergency Contact Phone Number

Ethnicity

Asian African-American Hispanic American Indian Caucasian Non-resident Other I choose not to answer

First semester at JCCRequired *

First year at JCC

Student StatusRequired *

If you transferred from another post-secondary institution, did you utilize the services there?

If you transferred from another post-secondary institution, did you utilize the services there? Yes If you transferred from another post-secondary institution, did you utilize the services there? No

Name of institution

Services received

Specific Accommodation Information

Did you receive accommodations in high school?

Did you receive accommodations in high school? Yes Did you receive accommodations in high school? No

Which accommodations did you receive in high school?Required *

Do you receive assistance from ACCES-VR?

Do you receive assistance from ACCES-VR? Yes Do you receive assistance from ACCES-VR? No

What is the nature of your disability?Required *

Please select all that apply and have documentation to support.

Is this a temporary disability?

Is this a temporary disability? Yes Is this a temporary disability? No

In your own words please describe your disability and check any of the major life activities that your disability affects.Required *

Please indicate which major life activities are impacted by your disability.Required *

Major life activities are defined by the ADA and are listed below. Your disability has to affect one or more life activities to qualify as a disability under the ADA and to receive services. Please check all that apply to your disability.

Breathing Caring for oneself Communicating Concentrating Eating Hearing Learning Lifting Operation of major bodily function Performing manual tasks Reading Seeing Sleeping Speaking Standing Thinking Walking Working

Do you have qualified documentation to support the diagnosis?Required *

Do you have qualified documentation to support the diagnosis? Yes Do you have qualified documentation to support the diagnosis? No

Please note

**Accommodation(s) that are being requested must be supported with qualifying documentation. Requesting an accommodation does not guarantee that accommodation. To send documentation to ASO after submitting the form, please email it to ....or login to JCC Accommodate.

Upload supporting document(s)

Please use the upload documentation button to attach documents to your registration form.

What services/accommodations are you requesting?Required *

Alternate Text

Braille

Breaks during class/test

Bring an Aide to class (student's responsibility)

Calculator/math tables

Class notes (Notetaker)

Digitally record lectures/labs

Extended time for exames/quizzes

Fidget apparatus

FM system

Food/drink allowed

Interpreting services

Kurzweil

Livescribe pen

Modified equipment (explain below)

Oral recitation of an exam/quiz

Preferential seating

Scribe

Separate location to take exams

Separate location to take exams (alone space)

Service animal (not legally required to register with the ASO)

Speech to text software

Text enlargement

Use of laptop during class

Word processor

Other (please specify)

26 of 26 visible

0 of 26 selectedshow selected show all

Other

Please specify

If you marked modified equipment please explain

Residential/Dining

Jefferson Community College provides access to reasonable accommodations for each qualified student with a disability through individualized services, specialized equipment, and a supportive environment. An Accommodative Specialist is the liaison between you and JCC Staff/Residence Life Staff as you reside in the residence halls. The College complies fully with the Americans with Disabilities Act Amendment Acts 2008 (ADA), Section 504 of the Rehabilitation Act, NYS Human Rights Law and the Fair Housing Act (FHA).

Reasonable housing/dining accommodation requests are reviewed on a case-by-case basis, and are determined upon the supporting documentation that is provided. All requests must go through the Accommodative Services Office (ASO) in the Collaborative Learning Center, 1st Floor.

Directions: Students requesting a housing or dining accommodation must complete this portion of the form. Once this form has been submitted, a complete packet (documentation requirements, release of information, etc.) will be sent to the student for him/her to complete and return to the ASO.

Are you going to be living on campus?Required *

Are you going to be living on campus? Yes Are you going to be living on campus? No

Have you filled out a Residence Hall application?Required *

Have you filled out a Residence Hall application? Yes Have you filled out a Residence Hall application? No

Have you submitted your deposit for living in the Residence Halls?Required *

Have you submitted your deposit for living in the Residence Halls? Yes Have you submitted your deposit for living in the Residence Halls? No

Do you require accommodations/services for the Residence Halls and/or dining facility?Required *

Do you require accommodations/services for the Residence Halls and/or dining facility? Yes Do you require accommodations/services for the Residence Halls and/or dining facility? No

Please state/describe the disability and limitations for everyday livingRequired *

Please state what accommodation is being request for housing and/or diningRequired *

In the event of an emergency evacuation or drill, does this disability require assistance?

In the event of an emergency evacuation or drill, does this disability require assistance? Yes In the event of an emergency evacuation or drill, does this disability require assistance? No

I certify to the best of my ability, that all of the information completed on this form is correct and the most up to date.Required *

Yes

ACCOMMODATIVE SERVICES RELEASE OF INFORMATION- PLEASE READ CAREFULLYRequired *

Your signature below gives the Accommodative Services Office permission to disclose information regarding your disability/disabilities to appropriate college personnel and affiliated agencies for the purpose of determining and arranging accommodations and those services necessary for meeting educational needs.

I understand that I am responsible for submitting current documentation specific to my disability/disabilities. Upon receipt and consideration of such documentation, accommodations/services will be determined and discussed during an interview with the Disability Specialist and/or designee. In addition I understand that provision of these accommodations/services may involve disclosing disability record information provided by me to appropriate college personnel participating in the accommodation process.

This release covers Accommodative Services ONLY. It does not cover a release for other College offices.

DOCUMENTATION RECEIVED IS PROPERTY OF THE ACCOMMODATIVE SERVICES OFFICE AT JEFFERSON COMMUNITY COLLEGE.

Yes

Confidential Registration Form

Student Information

Specific Accommodation Information

Residential/Dining

Document Information