Online Student Application

Questions

1. What is your Banner ID Number?
2.  

   Do you prefer to be called another name? (This name will be included on your ADA letter that is sent to your instructors.) * (Selection is Required)

   Yes

   No

   Additional Note or Comment
3. What is your preferred first name?
4.  

   Are you over the age of 17? * (Selection is Required)

   Yes

   No

   Additional Note or Comment
5.  

   Are you registered for classes and have a class schedule? * (Selection is Required)

   Yes

   No

   Additional Note or Comment
6.  

   Are you taking Dual Credit classes? * (Selection is Required)

   Yes

   No

   Additional Note or Comment
7.  

   Will you be living in the Wharton campus Residence Hall (Dorm Room)? * (Selection is Required)

   Yes

   No

   Additional Note or Comment
8.  

   Will you need a sign language intepreter? * (Selection is Required)

   Yes

   No

   Additional Note or Comment
9. What semester are you requesting accommodations for?
10. What accommodations are you requesting?
11. What is your primary disability?
12. What is your secondary disability?
13. Please list any other documented disabilities.
14. What is your program of study?
15. Emergency Contact Name. (In case of emergency, please provide the name of an individual whom we may contact on your behalf.)
16. Emergency Contant Phone
17. Relation to you. (i.e. parent, grandparent, sister)
18.  

    I give permission to contact my emergency contact listed above, if necessary. * (Selection is Required)

    Yes

    No

    Additional Note or Comment
19.  

    By checking the boxes below, I acknowledge that I have read and understand the statements below.

    I authorize the WCJC Office of Counseling and Disability Services staff and/or the Associate Vice President of Academic Affairs to have access to all of my academic records as required to assist me in planning and evaluating academic progress if needed.

    I give the WCJC Office of Counseling and Disability Services staff and/or the Associate Vice President of Academic Affairs permission to share relevant information on a need-to-know basis with WCJC administrators, faculty, and/or emergency personnel,to release relevant information to agencies that provide external support, and to request information about me from other campus offices.

    I give permission for the WCJC Office of Counseling and Disability Services staff and/or, the Associate Vice President of Academic Affairs to contact relevant external service providers (medical doctors, psychologists, audiologists, psychiatrists, etc.) who have provided information concerning my disability, to obtain information needed to determine appropriate and effective accommodations and services.

    I understand that submitting documentation and then completing this form and the Intake and Orientation checklist is the initial step in the accommodation process. Once I am registered with the WCJC Office of Counseling and Disability Services, I may need to meet with the Director of Counseling and Disability Services and/or Counseling staff as needed.

    I also understand that I am my own advocate. It is my responsibility to request accommodations and to notify instructors and testing center staff of my need for accommodations. It is my responsibility to report any concerns I may have regarding accommodations to the Director of Counseling and Disability Services and/or the Counselor/Disability Services staff.

    I understand that appropriate documentation of my disability must be provided to the WCJC Office of Counseling and Disability Services before accommodations will be provided. I realize that I may need additional documentation upon transferring from or to another educational institution. It is my responsibility to consult with the transfer institution regarding their documentation requirements.

    I am aware that the ADA Action Request/Letter of Accommodation with my accommodations will be sent to my WCJC student email account, and I am responsible for reading the email and forwarding the entire ADA Action Request/Letter of Accommodation individually to my instructors. The ADA Action Request/Letter of Accommodation will only list the accommodations provided to the student, the student’s name, and WCJC ID number, semester, and next steps for action.

    I am aware that the ADA Action Request/Letter of Accommodation is not retroactive and only becomes effective once the student and the instructor discuss the accommodations.

    I understand that despite my disability: 1) I must meet the minimum / technical standards as set forth by my program of study and the classes I take with or without accommodations, and 2) I am responsible for following the college policies and the code of student conduct that can be found in the Student Handbook, College Catalog, and online.

    Additional Note or Comment
20. Student Signature - by typing your name below, you affirm that you have completed this applicaton truthfully and have read and understand confidentiality statements hearin.
21. Date