Registration Form

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Registration Form2019-05-07T11:00:03-05:00
Office for Disability Services - Registration Form

Contact Information

Address *
Address
City
State/Province
Zip/Postal
Country

Program Affiliation

Program Affiliation
Degree Type

Student Responsibilities

I understand that it is my responsibility to meet with ODS to determine the accommodations I am eligible to receive while a student at Lincoln College. *
I agree to provide necessary documentation of my diagnosed disability, including information regarding the current impact of the disability for the purpose of establishing protection under the law and determining appropriate accommodations. I understand that this documentation is protected by FERPA and will be protected against misuse by others. *
I understand that it is my responsibility to learn about and use the various services provided by Lincoln College. I acknowledge that I am responsible for scheduling and participating in necessary appointments with the Office for Disability Services, instructors, testing services, and others involved in providing my accommodations. *
I understand that requests for accommodations must be submitted in writing in a timely manner. *
I acknowledge that it is my responsibility to keep the Office for Disability Services informed of my current contact information so that I may receive correspondence and notifications. *
I understand that I am responsible for the information contained in LC Student Handbook and the ODS Student Handbook (both available online). *
I acknowledge that it is my responsibility to complete all requirements for the course(s) and program(s) in which I enroll. *

Accommodation History

If you have used accommodations in the past, please list them and rate their effectiveness.
With 1 being "Not Effective", 2 being "Somewhat Effective" and 3 being "Very Effective", how would you rate your previous listed accomodation?
With 1 being "Not Effective", 2 being "Somewhat Effective" and 3 being "Very Effective", how would you rate your previous listed accomodation?
With 1 being "Not Effective", 2 being "Somewhat Effective" and 3 being "Very Effective", how would you rate your previous listed accomodation?
With 1 being "Not Effective", 2 being "Somewhat Effective" and 3 being "Very Effective", how would you rate your previous listed accomodation?
With 1 being "Not Effective", 2 being "Somewhat Effective" and 3 being "Very Effective", how would you rate your previous listed accomodation?

Requested Accommodations

Please list the academic accommodation(s) you are requesting. Include an explanation of how each accommodation would mitigate the impact of the disability. (Requests must be supported by submitted documentation and may not fundamentally alter the nature of the program or pose an undue administrative or financial burden on the College.)

Disclosure Agreement

In order to facilitate effective accommodations at Lincoln College, I authorize the Office for Disability Services to discuss relevant aspects related to my disability and accommodations with key individuals and offices at the College. Such communication will not include diagnostic information. Additionally, I authorize the Office for Disability Services to discuss relevant aspects related to my disability and accommodations to the persons listed below. I understand that this information is protected under the Family Educational Rights and Privacy Act (20 U.S.C. § 1232g; 34 CFR Part 99).
Do you need to add an Individual not associated with the College to whom information may be released
Do you need to add another Individual not associated with the College to whom information may be released
Do you need to add another Individual not associated with the College to whom information may be released
My signature below indicates my agreement to the following:
I acknowledge by my signature that I understand that, although I am not required to release my records, I am giving my consent to release the designated information to the above-named person(s). I understand that this consent will remain in effect unless I revoke such consent in writing and the revocation is received and processed by Lincoln College.
The above information is correct to the best of my knowledge. *
I release the following information to the Office for Disability Services: transcripts, test scores, progress reports, diagnostic data, and other information from the records pertaining to my enrollment. *
I acknowledge receipt of an ODS Student Handbook *
ODS Student Handbook is downloadable at http://ncods.lincolncollege.edu/students
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