Disability Services Request for Accommodations Form

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Please correct the field(s) marked in red below:

Term you are requesting accommoodations:
 *
Term you are requesting accommoodations:
BMCC ID:
 *
Last Name:
 *
First Name:
 *
Date of Birth:
 *
Phone Number:
 *
Mailing Street Address:
 *
City:
 *
State:
 *
Zip:
 *
Describe your disability/disabilities:
 *

Please submit Documentation of Disability from a qualified professional to the Student Health & Wellness Resource Coordinator by attaching file below, mailing, or dropping off at a BMCC Center.  Disability Documentation Requirements details here.

Please check accommodations below that you have been granted in the past or you believe would be helpful:
Assessment / Testing:
Assessment / Testing:
If other selected for Assessment / Testing please indicate here:
Academic:
Academic:
If other selected for Academic please indicate here:
Environment:
Environment:
If other selected for environment please indicate here:
Technology:
Technology:
If other selected for Technology please indicate here:
BMCC is an equal opportunity employer and educator
  1. To receive a copy of your submission, please fill out your email address below and submit.