MATC Reasonable Accommodation Request Form

MATC REASONABLE ACCOMMODATION REQUEST FORM

PROSPECTIVE STUDENT REQUESTOR ___ * STUDENT REQUESTOR ___

NAME: _______________________________________________DATE: _____________
ADDRESS: _______________________________________________________________
TELEPHONE: _____________________________________________________________
CAMPUS LOCATION OF PERSON SUBMITTING REQUEST: _________________________
NEED FOR ACCOMMODATION: _______________________________________________

________________________________________________________________________

REQUESTOR'S SUGGESTED ACCOMMODATION: _________________________________

________________________________________________________________________

DOCUMENTATION OF DISABILITY: (Please Attach)

MATC'S ACCOMMODATION PLAN: ____________________________________________

________________________________________________________________________

PLEASE SIGN AND DATE ONE STATEMENT ONLY!!!

I concur with the proposed accommodation:

DATE: ______________

________________________________
(Student Signature)

I wish to appeal the committee's proposal:

DATE: ______________

________________________________
(Student Signature)

FOR OFFICE USE ONLY

REQUEST RECEIVED BY:	___________________________________ ADA/504 Coordinator or Designee* Date

ACCOMMODATION APPROVED:	___________________________________ ADA/504 Coordinator or Designee* Date