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 prior to classes starting to ensure adequate time for accommodations to be arranged.

Student Information

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

Please use your FCC issued email address
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 am acknowledging 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.