Student Interview Form

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Services for Individuals with Disabilities Walters State Community College Student Interview Form
Student Support Services	\|	Disability Services	\|	Disability Qualification	\|	Services Available	\|	Teaching Dis. Students	\|	Interview Form

Student Status:	Full-Time Part-Time	Semester:	Fall Spring Summer
Today's Date:

First Name:
Middle Initial:
Last Name:
Address:
City:	State: Zip Code:
Email Address:
Phone:	Other:
Major:
Description of Disability:

Request Accommodations (please check):
Textbooks on Tape Tutorial Services Note Takers Testing Evaluation Accommodation Large Print Exams Interpreter Assistance Extended Time for Test Tape Player
	Use of Calculator Reader Library Assistant Lab Aide Test Isolation Adjustable Table Temporary Disabled Parking Use of Computer or Other Adaptive Equipment Other

I understand that an Educational Support Plan will be mailed to my class instructor/instructors upon request (request must be submitted each semester).

An Affirmative Action/Equal Opportunity Employer.We comply with Title IX of the Education Amendments of 1972, the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990.

Walters State Community College · 500 South Davy Crockett Parkway · Morristown, TN 37813-6899
Phone: (423) 585-2600 · Toll Free: (800) 225-4770 · Contact Walters State

Services for Individuals with Disabilities Walters State Community College Student Interview Form

Services for Individuals with Disabilities
Walters State Community College Student Interview Form