Public Accommodation Request

Student Information

Please enter your information

First Name

Last Name

Middle Name

HVCC Student ID#

Include only the 8 digits of your H#

HVCC Email

Please use your HVCC issued email address (ex. e-example@hvcc.edu)

Phone Number

Semester to begin studies

Year to begin studies

Will you be enrolled full time?

High School Name

High School Graduation Date

High School Address

Specific Accommodation Information

Please describe your diagnosed disability(ies)

How does your disability impact your life as a student?

Please describe the accommodations you have received in the past

Special Mobility Needs

Accessible Classroom

Emergency Evacuation

Outside Agency Information

Are you working with an outside agency?

Upload supporting document(s)

Click Here to access the Release Authorization Form. This form, along with your supporting documentation must be submitted before accommodations can be approved.

Consent

By submitting this form the student gives the Center for Access and Assistive Technology permission to advocate on their behalf with other offices on campus.

Public Accommodation Request

Student Information

Specific Accommodation Information

Special Mobility Needs

Outside Agency Information

Document Information