Request for Services Application

* indicates a required field

Disability Access Services at Frederick Community College
The Disability Access Services Office (DAS) strives to reduce the impact of a disability on a student's opportunity to learn and participate in campus life. Qualified students who self-identify and provide appropriate documentation of a disability are eligible for reasonable accommodations as described in Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act and amendments. We encourage students to request services as early as possible before classes start to ensure adequate time for accommodations to be arranged. Students must supply documentation of their disability and meet with Disability Access Services to be approved for accommodations. This application does not guarantee approved accommodations; each request will be evaluated case-by-case, and accommodations are not retroactive.

Student Information

To request services/accommodations, please complete all sections below (must be completed by the student).

Please do NOT include the "W" in your student ID; only use numbers.

Please use your FCC-issued email address. For example

Pronouns you would like for us to refer to you by (she/her/hers, they/them/theirs, he/his/him, or something else). This question is voluntary.
If you are still in high school, please choose where you will be enrolled in FCC classesRequired
This could be the high school from which you graduated or college from which you are transferring

Disability and Accommodation Information

Disability StatusRequired
(Students must have a documented disability to be eligible for services
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Accommodation Information

Depending on the courses for which I am registering, I may need the following type of accommodation(s).

**Please note that answering yes below does not ensure the provision of a specific accommodation. Appropriate documentation must be submitted and reviewed before a student’s eligibility for accommodations can be determined.

Classroom (virtual or face-to-face) accommodationsRequired
Testing accommodationsRequired
Have you used accommodations previously (in K-12 setting or another post-secondary institution)?Required

Documentation and Policies

FCC Release of InformationRequired

I understand that personnel in the DAS may need to communicate with faculty, staff, and other personnel at FCC in order to provide accommodations for my disability. I understand that this is for the purpose of coordinating accommodations, and DAS personnel do not share diagnostic information unless it is on a need to know basis. This authorization is for internal FCC purposes, and it does not include permission to release information to a third party. 

This consent is valid during my entire enrollment at FCC. I understand that I may revoke this consent at any time by submitting to the DAS a written revocation that is signed by me and witnessed by another person who knows me.

I authorize personnel in the DAS to release information about my interactions with the DAS to outside parties listed here (family, providers, etc.):

Please list specific names (example: Sue Jones instead of "mom"). You may choose to leave this blank. If you do not wish to release information to outside parties (family, providers, etc.), please enter "not applicable" in the text box. 

DAS Student Rights and Responsibilities AgreementRequired

By checking below, I (an FCC student) acknowledge my understanding of these procedures and willingness to comply with all DAS requirements. Please click here to read the DAS Student Rights and Responsibilities Agreement.

I am reporting a disability and am requesting services from the Disability Access Services Office to participate in a College-sponsored program or activity. To receive services, I must agree to the following items by clicking that you agree in the below checkbox.

  1. Consent to release information about my disability and accommodations to appropriate college personnel, including faculty, staff, interpreters, etc., only to the extent necessary to allow me to participate in College programs and receive the support necessary for successful course completion. 
  2. I will provide copies of documentation to support my request for accommodations. Copies will be destroyed after six years from the last use of accommodations at Frederick Community College. If documents are received, but services are not initiated, all documentation will be destroyed six years after receipt. 
  3. I agree to follow up with each professor after I submit a semester request(Accommodation Plan) to discuss my accommodations and how they will be implemented.
  4. I am responsible for submitting a semester request each semester to receive accommodations for my courses. I understand that professors will not provide accommodations until they receive the semester request from Disability Access Services.
  5. I also understand that if I receive a provisional accommodation plan for one semester, I must provide documentation that meets the Disability Access Services guidelines before the accommodation plan is renewed. 
  6. If approved for accommodations, I understand I need to notify Disability Access Services as soon as possible if there are questions or concerns about my accommodations.
  7. I will inform the DAS Office in the event of course adds, drops, or changes so that DAS can make the appropriate adjustments to my semester requests.