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Ivy Tech Community College

Special Needs Services

REQUESTING ACCOMODATIONS

FOR A DISABILITY

Ivy Tech Community College seeks to provide effective services and accommodations for otherwise qualified individuals with documented disabilities.

To request special services or academic accommodations, you must:

1. Contact Special Needs Services at the telephone or address below.

(No action can be taken without a specific request from the individual needing the assistance.)

2. Complete and return this request form. (See the back of this page.)

3. Provide us with professional documentation of your disability, that:

Ø describes the disability.

Ø Gives significant support for the accommodations requested.

o Usual sources for this information include:

§ High school educational plan & special psychological testing

§ Vocational Rehabilitation evaluation

§ Doctor’s letter or medical records

4. Provide us with your official high school or GED transcript.

(This must show your graduation date and be sealed in the school’s envelope.)

If you have questions, please call Don Heiderman at (812) 265-2580 or (800) 403-2190 extension 4114.

Please return request form and needed information to:

Madison Campus Lawrenceburg/Batesville Campus

Don Heiderman Carla Good

590 Ivy Tech Drive 500 Industrial Drive

Madison, IN 47250 Lawrenceburg, IN 47025

(812) 265-2580 or (812) 537- 4010 or

(800) 403-2190, Ext. 4114 (800) 715-1058 Ext. 239

We want you to succeed at Ivy Tech!

Every effort will be made to provide reasonable accommodations in a timely manner. Please allow a reasonable amount of time after we have received all necessary information (approximately one week) for us to professionally evaluate and respond to you needs.

Ivy Tech Community College

Special Needs Services

REQUEST FOR ACCOMMODATIONS

FOR A DISABILITY

PLEASE NOTE: The instructions on the other side of this form must be followed before we can assist you.

Date__________________________

Are you a (circle one) new / current / former Ivy Tech student.

If not currently attending, when do you plan to start school at Ivy Tech?____________

Name______________________________SSN_______________________________

Address_______________________________________________________________

______________________________________________________________________

Telephone_________________________________TDD? Yes or No

1. What is your disability?

2. What accommodations are you requesting?

Any information shared with us will be kept confidential unless the student specifically authorizes its release.

I give approval to Ivy Tech Needs staff to talk with these people about my educational needs:

(List): ____________________________________________________________

____________________________________________________________

_____________________________________________________________

_______________________________

(Student Signature)