COVID - Student Intake Agreement

Disability Services Office COVID19: Student Accommodation Intake Agreement
Masks/Face Coverings must be worn by all SCC employees and students while in classrooms, offices, hallways and general areas within all SCC facilities. Students are required to bring and wear their own face mask while they are in SCC facilities. Students who have a health condition that may exempt them from wearing a mask should complete this form online and then return necessary medical documentation to Dr. Derreck Calkins or Angie Mickelson in the Student Support Center(s) located in Room 102 on the West Burlington Campus and Room 206 on the Keokuk Campus. Upon receipt of valid documentation from a qualified healthcare provider, the Disability Services Office will determine eligibility and appropriate COVID 19 related accommodations.
Student Name*
First NameLast Name
Student Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Date of Birth*
MonthDayYear
Date
Student Email Address*
example@example.com
Home Phone Number
Area CodePhone Number
Mobile Number
Area CodePhone Number
Describe the needed modification that you are requesting? *
What is your diagnosed disability? *
MY RESPONSIBILITIES: As a student eligible for accommodations through Disability Services, per the Rehabilitation Act of 1973, Section 504, and the Americans with Disabilities Act of 1990, I understand that I also have certain responsibilities. I will do my part in meeting the responsibilities listed below so that appropriate accommodations may be arranged.
1. Provide appropriate documentation to support the accommodations requested.
2. Understand that accommodations must be requested in a timely fashion to obtain the most appropriate accommodation available.
3. Fill out an Accommodation Request Form each semester that I desire accommodations. Please note that this process and any adjustments that result due to COVID 19 are temporary and should not be confused with the Disability accommodations, which is an entirely separate manner.
4. Notify Disability Services of changes in my schedule as soon as I know about them. Failure to do so may result in a delay of accommodations.
5. Schedule an appointment with the Disability Services Coordinator if I have any concerns or questions related to my accommodation(s).
Information contained within your Disability Services file will be kept confidential and will not be shared with anyone outside SCC without your expressed authorization.
I, the undersigned, understand and agree to fulfill the above responsibilities.
Student Electronic Signature*
Clear
It is the policy of Southeastern Community College to select, develop, and promote employees and students based on individual ability and performance. It has been, and shall continue to be, the policy of Southeastern Community College not to discriminate on the basis of race, creed, color, sexual orientation, gender identity, national origin, sex, disability, religion, or age in its programs, activities, or employment practices as required by the Iowa Code sections 216.9 and 256.10(2), Titles VI and VII of the Civil Rights Act of 1964 (42 U.S.C. § 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C.§§ 1681 – 1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. § 794), and the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.). Individuals having questions or complaints related to compliance with this policy should contact Human Resources, Southeastern Community College, 1500 W. Agency Road, West Burlington, IA 52655, phone number 319/208-5063, fax 319/208-5006 or the Director of the Office for Civil Rights, U.S. Department of Education, Citigroup Center, 500 W. Madison, Suite 1475, Chicago, IL 60661, phone number 312/730-1560, fax 312/730-1576.
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Disability Services Office COVID19: Student Accommodation Intake Agreement