Application for Services and Resources

Application for Services and Resources
Student Name*

First NameLast Name
Date of Birth*

MonthDayYear
Student ID Number
Ten digits, starts with a "62" or a "76"
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Have you applied with Southwest Tech?*

YesNo
Have you met with an Academic Advisor?*

YesNo
Start Date/Anticipated Start Date*

MonthDayYear
Program or Program of Interest*
The college cannot authorize an accommodation unless the request is supported by documentation from a qualified source. Do you have access to official records that confirm the diagnosed disability and/or limitations that you can provide to the ADA Coordinator?*

YesNoNot Sure

Identify any disability for which you may require an accommodation:*
Describe how your disability/disabilities will limit or affect your activities at the college:*
Identify any accommodations or services that will enable you to overcome the limitation(s) indicated above:*

STUDENT AGREEMENT

Instructions: Please read each of the following statements and indicate your agreement by selecting each item. If you have questions about these responsibilities, discuss them with your Advisor.
Type a question*

Provide Student Services with appropriate documentation, as required by ADA, of disability, i.e., medical records, psychological evaluations, high school special records to verify my initial eligibility and may be required to provide periodic updates of such documentation.Discuss the functional limitations caused by my disability and assist the ADA Coordinator in determining which accommodations are appropriate.Meet with the ADA Coordinator to review my academic progress and needed accommodations.Take responsibility for my education at Southwest Tech and obtain assistance from Student Services and make contacts with instructors and service providers when appropriate.Contact the ADA Coordinator when changes occur, services are interrupted for any reason, or a problem occurs with a service provider.Adhere to the college polices.Maintain borrowed equipment in good condition and return in a timely manner.
Acknowledgment:

By selecting the items above and by signing this form, I acknowledge my understanding of each of these responsibilities and verify that I have had an opportunity to ask questions and discuss these responsibilities with the ADA Coordinator.
Signature*

Clear
After submitting this form, please schedule an appointment with the ADA Coordinator and bring your supporting documentation with you to your appointment.
Should be Empty:

Application for Services and Resources

STUDENT AGREEMENT

Acknowledgment:

After submitting this form, please schedule an appointment with the ADA Coordinator and bring your supporting documentation with you to your appointment.