Student Accommodation Request Form

Student Information

Completing this online intake form is the first step in the interactive accommodations process at Delaware County Community College. After submitting this form, please review the documentation guidelines on our website to ensure you provide the required materials. Please ensure all information on this form is accurate, including your full name and student ID number. Forms submitted with missing or incorrect information cannot be processed.

First Name

Last Name

Student ID (P Number)

Email

Please use your DCCC issued email address

Preferred Name

Pronouns

For which semester are you requesting these accommodations?

Are you currently registered for courses?

Enrollment Status

What is your current enrollment status?

Please select at most 2 options.

Which campuses do you utilize? Please choose all that apply

Disability Information

Please complete all required sections

Please select your diagnosis or diagnoses. Select all that apply using the Ctrl (Windows) or Command (Mac) keys.

Other

Academic Accommodations

Please complete all required portions. If unsure, select/specify N/A

Have you previously received accommodations via another school/college?

Which accommodations are you seeking?

Upload supporting document(s)

Link to documentation guidelines: https://www.dccc.edu/student-services/support-services/disability-services/disability-documentation-requirements