application for accommodations

Name

First Name

Last Name

NEMCC ID

Date of Birth

Address

Address Line 1

Address Line 2

City

State

ZIP Code

Email

Phone

Gender

Male Female

Dorm / Room Number

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone Number

Are you a U.S. citizen?

yes no

Are you a new student?

yes no

Which of the following categories best describes your primary disability?

When were you diagnosed with a disability?

Major life activity with which this condition interferes. Check all that pply.

Manual Tasks Walking Seeing Hearing Breathing Learning Speaking

Limitations imposed by disability. Check all that apply.

Organizing/Sequencing Easily Distracted Poor Concentration Difficulty Focusing for Extending Periods of Time Difficulty Formulating & Executing Plan of Action Abstract Thinking Panic Attacks Other

Please list accommodations previously received/accommodations requested:

List all medications with side effects. Check all that apply.

Are you a client of Vocational Rehabilitation (VR) Services?

yes no

In compliance with Title VI of the Civil Rights Act of 1964; Title IX, Educational Amendments of 1972 of the Higher Education Act; and, Section 504 of the Rehabilitation Act of 1973, as amended, the Board of Trustees of Northeast Mississippi Community College has adopted this policy assuring that no one shall, on the grounds of race, color, age, national origin, or sex, be excluded from participating in, be denied the benefits of, or otherwise be subjected to discrimination in any program or activity of the College. Northeast Mississippi Community College adheres to the principle of equal educational and employment opportunity without regard to race, sex, age, color, creed, or national origin. This policy includes the qualified handicapped and extends to all programs and activities supported by the College. The Section 504 Coordinator is Leigh Ann Stewart, Wright Hall (662)720-7192 and the Title IX Coordinator is Liz Roark, (662)720-7223.

I hereby authorize NEMCC's Office of Disability Accommodations to communicate with the following:

Parents NEMCC Faculty/Staff, On-Campus Services (Student Services, Housing, etc.) Off-Campus Services (Professionals, School, Vocational Rehabilitation, etc.)

Are there any communication exclusions?

Yes No

Please list any exclusions: *

Please upload your documentation here:

No File Chosen

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I understand that the Office for Disability Accommodations will not disclose my records to others unless I give permission for them to do so or unless the law authorizes or compels them to do so.

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