Student Accessibility Services Intake Form Step 1 of 4 25% Please fill out the information below to register with NCKTC Student Accessibility Services and begin the process for requesting support services.Email(Required) Name(Required) First Last Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone(Required)What is the best way to contact you? Email Phone Text Other Other Contact Method Date of Birth MM slash DD slash YYYY NCK Tech Program: Campus Location Beloit Hays How did you hear about us? ADA statement on course syllabus Another student College Instructor College Staff College catalog/materials High School Parent Vocational Rehabilitation Services Website Other Other way you heard about us: Are you a client of Vocational Rehabilitation Services (VR)? Yes No Maybe If you answered "yes" to the previous questions, please provide your case manager's name and contact information. Part 2 - School HistoryHigh School Attended: High School Graduation Year: What accommodation/support services did you receive in high school? Other Colleges Attended (if applicable): Dates Attended (Other college): What accommodations/support services did you receive while in college? Part 3 - Disability InformationDisability (please check all that apply). Documentation of disability must be provided. Acquired brain injury ADD/ADHD Autism Spectrum Blind/Low Vision Deaf/Hard of Hearing Developmental Disability Health Impairment Language Impairment Learning Disability Mental Health (Depression, Anxiety, etc.) Physical/Mobility Impairment Speech Impairment Temporary Disability Other Other Please describe how your disability impacts you in the classroom: Part 4 - AccommodationsPlease list any academic accommodations or support services that you would like to request at NCK Tech. For questions about this form, please contact Jayme Owen, Dean of Student Success at 785-738-9037 or email at jowen@ncktc.edu(Required) I understand Documentation of disability is required. Please email your documentation to jowen@ncktc.edu or fax to 785-738-2903, attention: Director of Learning Services. Once documentation is received and approved, you will need to meet with a Student Accessibility Services staff member to discuss accommodations, procedures, and policies. Informatoin regarding disability is kept in the office of the Student Accessibility Services and is not part of the student's permanent record. All documentation received by NCK Tech Student Accessibility Services Office will be stored in accordance with all state and federal laws. For more information on documentation guidelines: https://ncktc.edu/disability-services/accessibility-documentation-guidelines/(Required) I understand NCK Tech is committed to nondiscrimination on the basis of race, color, gender, ethnic or national origin, sex, sexual orientation, gender identity, marital status, religion, age, ancestry, disability, military status, or veteran status in admission or access to, or treatment or employment in, its programs and activities. Further, it is the policy of the college to prohibit harassment (including sexual harassment and sexual violence) of students and employees. Any person having inquiries concerning the college's compliance with the regulations implementing Title VI, Title VII, Title IX, Section 504, and the Americans with Disabilities Act Amendments Act is directed to the Dean of Instructional Services (Section 504/ADA Compliance Officer) or the Vice President of Students and Instructional Services (Title VI, Title VII, & Title IX Compliance Officer) at 1-800-658-4655 or PO Box 507, 3033 US Hwy 24, Beloit, KS 67420.(Required) I understand Send me a copy of my responses. Yes No Δ
