Accommodation Request Form

Accommodation Request Form
Vance-Granville Community College’s Office of Counseling, Accessibility, & Support Services (CASS.) provides an environment designed to collaboratively work with both students and instructors to ensure equity in accessibility for individuals seeking accommodations. By completing this form, you are voluntarily identifying yourself as an individual with a diagnosis that meets the requirements of Section 504 of the Rehabilitation Act of 1973, the 1990 Americans with Disabilities Act (ADA) and the 2009 ADA Amendments Act. Call or email the CASS Office at 252-738-3350 or accessibility@vgcc.edu if you require further assistance.
Name*

First NameLast Name
Student ID Number*
Semester for which you are requesting services*

FallSpringSummer
Year*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
VGCC Email*
example@vgcc.edu
Email (Other)
Cell Phone Number
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Please state the diagnosis from a licensed professional.*
Before accommodations can be implemented you must provide appropriate documentation of your disability and meet with the Coordinator of Counseling, Accessibility, & Support Services to discuss the request. Please specify the accommodations you are requesting, based on the documented diagnosis. (Check all that apply).*

Extended testing timeIsolated Distraction Reduced EnvironmentRecording Device in classesReaderWheel-chair accessible roomsBooks in alternative formatScribeTeacher NotesNotes in MoodleEbooks to allow read aloudSign Language/Oral InterpretersCaptioned video lectures with transcriptEnlarged MaterialOther
Documentation is necessary because a professional assessment is the basis for determining reasonable services and accommodations. Documentation guidelines are located on the CASS Department site.
Documentation Guidelines
Should be Empty:

Accommodation Request Form

Documentation Guidelines