Online Student Application

How do you see these accommodations relating to your disability? How will they support you? Please describe: * (Required)

Why were you given those accommodations? How were they helpful for you? Please describe: * (Required)

 

Have you experienced difficulty in any of the following academic areas? (Check all that apply.)

Reading

Spelling

Math

Taking tests

Study skills

Reading rate

Comprehending concepts

Retaining information

Completing assignments on time

Organization

Motivation

Other (Specify Below)

Additional Note or Comment

 

Do you have any current significant problems with social interactions with other people? Please describe:

Yes

No

Additional Note or Comment

 

Do you have any current emotional problems that significantly interfere with your ability to learn? Please describe:

Yes

No

Additional Note or Comment

 

Have you used any accessible/assistive technology before, including reading or writing software? Please describe:

Yes

No

Additional Note or Comment

 

Is there any other information you would like to share relating to your disability? Please describe:

Yes

No

Additional Note or Comment

Emergency Contact Information: Provide the following information in the box below, name, relationship, and phone number * (Required)

 

Office of Student Accommodations Release of Information and Procedures for Emergency Medical Occurrence:

If your disability could possibly create a situation where you would need emergency assistance please answer yes or no

Yes

No

If yes, there will be a separate form offered for you to complete with the counselor during your initial meeting. This form will be kept on file for the spring, fall, and summer of 1 school year.

Additional Note or Comment

 

I also give consent for Reynolds Community College to release information to appropriate persons and/or agencies or institutions as per my request. Please check all the apply.

Medical Records

Learning Disability Assessment Reports

Psychiatric Evaluation Results

Vocational Rehabilitation Plan

Audiology and Speech/Language Pathology Report

Accommodation Notification Form

Other (Specify Below)

I give further permission for Office of Student Accommodations (OSA) to discuss my educational situation with other professionals who have a legitimate educational need to know. This authorization shall remain in effect until revoked in writing by the student or by Office of Student Accommodations (OSA), whichever comes first (not to exceed two years from the date submitted.)

Additional Note or Comment

 

OFFICE OF STUDENT ACCOMMODATIONS STUDENT’S RESPONSIBILITIES - Please check each box as you read. You must type your full name in the comment box. This acknowledges that you have read and agree. Must be signed.

I must request accommodations at the beginning of each semester.

Complete this step by following directions for renewing your accommodations for the upcoming semester on our web page https://www.reynolds.edu/student_services/accommodations/default.aspx

I have the right and responsibility to disclose my disability to instructors, program supervisors or other parties when and if I choose to initiate a request for accommodations.

I am responsible for scheduling with my instructor all tests to be taken using my accommodations:

If taken on line communicate with your instructor about the extension of test time.

If taken on campus communicate with your instructor the location test will be taken at:

College Testing Center or the Testing Center inside the Office of Student Accommodations.

This step MUST BE scheduled at least 3-5 days in advance of the test date as appointment are made on first come and space available.

This is required to ensure that the test will be waiting for the student when they arrive to take a test.

I must inform my instructor if I have a scheduling conflict that requires the accommodated test to be taken more than three hours after the regularly scheduled classroom test.

I will be sure to allow enough time to complete the test:

on line by the published deadline date

on campus if using College Testing Center or the Testing Center inside the Office of Student Accommodations

Tests must be completed during the published hours for each location and by the deadline date provided by the instructor

I will contact the Instructor and/or the Office of Student Accommodations, in the event of an Emergency, to inform them and make the necessary schedule changes.

I will be on time to all classes and tutoring sessions.

I will notify the Office of Student Accommodations if I need books in alternate format at the start of each semester and will follow appropriate procedures for requesting books.

I will notify the Office of Student Accommodations if I need notes transcribed, enlarged, or other specialized services, at the start of each semester by providing copies of my syllabus to assist in scheduling & delivery of those services.

Additional Note or Comment

 

Commonwealth of Virginia Voter Registration Agency Certification - must be answered

If you are not registered to vote where you live now, would you like to apply to register to vote here today?

I am already registered to vote at my current address

I am not eligible to vote and do not need an application to register to vote.

Yes, I would like to apply to register to vote (please ask counselor at initial appointment for assistance. (fill out the voter registration application form).

No, I do not want to register to vote.

Additional Note or Comment

Additional Note or Comment