Disability Accommodation Application

Disability Accommodation Application
Office of Accommodations

Main Building 3rd Floor #307

(254)-298-8335
Student Name

First NameLast Name
Student Temple College ID #
Add your student ID#
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Describe the nature, extent and duration of your disability and how it affects you in the classroom- Can be a medical, physical, mental or learning disability.
Please upload any related supporting documentation.

Cancelof
Please indicate what types of accommodations you need to provide you with equal access to the education we provide at Temple College.
Name of the Health Care Provider or School District Contact
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I, named student/applicant above, acknowledge that any information about my medical condition can be requested from my health care provider for this accommodation request. I also acknowledge that release of information regarding my medical condition can be released to the Accommodations Office for the acceptance of this request
Date

MonthDayYear
By typing your name and submitting this form you agree to the terms of the form and understand you are applying for accommodations.
Student/Applicant Signature
Should be Empty:

Office of Accommodations