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Header Two
Home
Student Services
Student Accessibility Services
Forms
Student Intake Form
Student Intake Form
If you see this don't fill out this input box.
Name
*
College Wide ID Number
*
Mailing Address
*
City
*
State
*
ZIP Code
*
Phone
*
Primary Disability
*
Secondary Disability
Select Campus
*
City Park Campus
West Bank Campus
Charity School of Nursing
Jefferson Site
Sidney Collier Site
Are you a client of Louisiana Rehabilitation Services?
Yes
No
What is your rehabilitation counselor's name?
What is your rehabilitation counselor's phone number?
The accommodations and services will not be provided until you have turned in approved disability documentation.
Send documentation to disabilityservices@dcc.edu
. The documentation guidelines will be provided to the students with disabilities.
If the need arise, would you allow the disability services coordinator to discuss your academic performance with instructors, administrative staff, and/or rehabilitation counselors?
Yes
No
I understand that all information will be kept confidential unless I have specified its release. The name listed below will serve as my digital signature.
Your Name
*
Date
Form UUID
Site Name
Submit
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