Disability Services Classification and Registration

Company

This field is for validation purposes and should be left unchanged.

Personal Information

Name*

First Middle Last

Preferred Name

Enter your preferred name here if you use a name different from above.

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Student Email*

Your Lanier Technical College Student Email address. ex: jdoe@student.laniertech.edu

Enter Email Confirm Email

Alternate Email

Your alternate or personal email address, if you would like to provide one. ex: gmail, yahoo, outlook, etc.

Enter Email Confirm Email

Date of Birth

Special Populations Classification

Check all that apply.

I am a person with a disability. (Anyone with a physical or mental impairment that substantially limits one or more major life activities, such as caring for one’s self, performing manual tasks, walking, seeing, hearing, speaking, breathing, learning, and working.)

I am a person who has the primary or joint custody for a dependent child. You may be divorced, widowed, legally separated, never married or a person who is single and pregnant.

I have been financially supported by another family member in the past and that financial support no longer exists.

I am unemployed or underemployed and having difficulty obtaining or upgrading employment.

I have custody of one or more children with less than two years remaining to receive Title IV Social Security assistance.

Anyone with a physical or mental impairment that substantially limits one or more major life activities.

English is NOT my first language. I have difficulty speaking, understanding, reading, or writing English.

English is NOT my first language. I do NOT have difficulty speaking, understanding, reading, or writing English.

None of the above special populations categories applies to me.

Request for Services, Confidentiality of Disability Records and Consent

The Office of Accessibility Services is committed to ensuring that all information and communication pertaining to a student’s disability is maintained as confidential as required or permitted by law. Our guidelines concerning the treatment of such information are as follows:

No one will have immediate access to student files in this office except for appropriate staff from this office. Any information regarding a disability is considered confidential and will be shared only with others within the college who have a legitimate educational interest.
This information is protected by the Family Educational Rights and Privacy Act (FERPA).
Sensitive information in or student files will not be released except in accordance with federal and state laws and extreme exceptions such as child abuse, suicide, or homicidal intent (according to state laws).
A student’s file may be released pursuant to a court order or subpoena.
If a student wishes to have information about his/her disability shared with others, the student must provide written authorization to this office. Before giving such authorization, the student should understand the purpose of the release and to whom the information is being released.
The student should understand that there may be occasions when the Coordinator will share information regarding a student's disability if circumstances necessitate the sharing of information that the Coordinator has determined an appropriate legitimate educational interest.
A student has the right to review his/her own Accessibility Services file, with reasonable notification.

Accessibility

I hereby authorize Lanier Technical College to obtain documentation to support my stated disability(s) and to contact and discuss this information with necessary Lanier Technical College faculty/staff and applicable support agencies. I understand that the purpose of communicating any such information is allow the college to plan for any accommodations and adjustments that may be necessary in order to provide an equal educational opportunity. I have been advised to inform the office of any changes in attendance each semester. I understand that all aspects of my financial aid (including any sponsorship from agencies outside the college) are my responsibility. Furthermore, I understand that in order for Lanier Technical College to discuss documentation, release test scores or grades to parents, guardians, spouses, or other interested parties, I must authorize this action.

Please list the names and relationships of persons you authorize to access this information:

First Person

Name

First Last

Relationship

Phone

Email

Second Person

Name

First Last

Relationship

Phone

Email

Signature*

Today's Date*

Consent to Notify Instructors of Accommodations

When requesting accommodations, I understand that completing the interactive process including:

Self-Identification and Registration with Accessibility Services
Providing Current Medical Documentation
Completing Intake Meeting with Accessibility Services Coordinator

serves as my consent to have the reasonable accommodations for which I am determined to be eligible sent to my instructors each semester I participate. In the event I am granted provisional or temporary accommodations, it is my responsibility to ensure that I provide the required medical documentation to continue receiving services past the expiration date. I must also provide written notice via email to adacoordinator@laniertech.edu, if I would like to withhold notification of my accommodations for a given semester.

Signature*

Today's Date*

Student Responsibilities

I understand I may not be eligible to receive services until I provide current and sufficient documentation of my disability (see Documentation Guidelines). Certification of a disability will be requested only once, unless the disability is determined to be temporary, additional accommodations are requested, or the disability diagnosis changes.
I understand that it is my responsibility to schedule my intake meeting to discuss accommodation needs with the Coordinator of Accessibility Services to comply with the interactive process.
Classroom accommodations are based on the doctor's or other qualified professional's evaluations/medical documentation. (If you find that you need additional help, please notify the Coordinator of Accessibility Services.)
I understand that it is my responsibility to contact the Coordinator of Accessibility Services to request changes to my approved accommodations or discuss additional needs.
It is my responsibility to keep the Coordinator of Accessibility Services informed of my progress and to notify them if I add or drop a class, or withdraw from a course.
I understand that a copy of the accommodation(s) deemed appropriate will be retained in my file while I am a student at Lanier Technical College.
I understand that it is my responsibility to check and respond to my Lanier Technical College student email to remain updated on the policies and procedures of the Accessibility Services Office.
It is my responsibility to keep all organizations assisting me up to date. (Georgia Vocational Rehabilitation Agency, Veteran's Affairs, etc.).

Students with disabilities have the responsibility to:

Meet the essential qualifications of the chosen program of study, and comply with the academic, technical, and institutional standards of Lanier Technical College.
Identify themselves in a timely manner as an individual with a disability when seeking accommodations.
Provide the Coordinator of Accessibility Services with documentation from an appropriate source that verifies the nature of the disability, functional limitations, and the need for specific accommodations.
Follow procedures for obtaining reasonable and appropriate accommodations, academic adjustments, and/or assistive technology.
Maintain communication with the instructor and Accessibility Services, as needed.
Request any approved testing accommodations in advance of test dates by utilizing the appropriate Test Request Form provided at the start of each term or by contact the Office of Accessibility Services at adacoordinator@laniertech.edu.
Request Certification or Board exam accommodations from the relevant testing board well in advance of the exam.
Use accommodations appropriately.
Follow the Code of Conduct set forth by Lanier Technical College.

Students with Disabilities have the right to:

Equal access to courses, programs, services, jobs, activities, and facilities available through Lanier Technical College.
Reasonable, appropriate, and effective accommodations, academic adjustments, and/or assistive technology determined on an individual basis.
Appropriate confidentiality of all information pertaining to their disability except as required by law.

Signature*

Today's Date*

Audio Recording Agreement

Students with disabilities who qualify for the accommodation “Audiorecord Class Lectures” or “Note-taker” have the right to record class lectures for their personal study only. (84.44 Section of 504 in the Rehabilitation Act of 1973 P.L. 93-112, amended P.L. 93-516). Lectures recorded for this purpose may not be used in any way against the faculty member, other lecturers, or students whose classroom comments are recorded as part of the class activity. Information contained in the recorded lecture is protected under federal copyright laws and may not be published or quoted without the express consent of the lecturer and without giving proper identity and credit to the lecturer.

Student Pledge

Signature*

Today's Date*

Disability Services Classification and Registration