First Name:

Middle Initial:
Last Name:
E-mail Address:
Cowley E-mail Address:
Home Phone:
Cell Number:
Work Number:
Address:
City:
State:
Zip:
Campus Location:
Are you enrolled in the IMPACT program? Yes No
Do you receive assistance from Vocational Rehabilitation? (SRS)? Yes No
If yes, who is your counselor?

Disability: (Check all that apply)
Acquired Brain Injury Learning Disabilities Chemical Dependence ADD/ADHD Orthopedic/Physical Disability Temporary Disability Blind Psychiatric Disability Partial Sight/low vision Medical Disability Deaf Speech Disability Hard-of-Hearing Other (Explain)
Accommodations: (Check the accommodations you feel would benefit you in classes at Cowley. Accommodation approval is based on supporting documentation of the disability)
Extended test time Test in distraction reduced site Test read to me Note taker Record Lectures Assistive Technology Software Textbook in alternate format Calculator Enlarge Print Material/Handouts Interpreter (Sign) Closed Caption Video Preferred seating Scribe Listening Device Other

This Program Application, along with current documentation, should be forwarded to the Disability Services Office at Cowley College. It is important that students who are planning to request accommodations submit their documentation to the Disability Services office as soon as possible. Services are gladly provided to qualified applicants on a first-come first-serve basis; however, we can not be held responsible to provide a service when the resource available is limited or no longer available. Though we shall make every attempt to provide qualified applicants with appropriate accommodations, as available, it is incumbent upon the student to apply for services as soon as possible.

Submit documentation to:

Mark A. Richardson, Disability Services Coordinator
125 S. Second St. P.O. Box 1147
Renn Library Room 107
Arkansas City, Kansas 67005

Release of Information forms are available in the Disability Services Office or on the Website:
Click Here

I understand that this form does not constitute an agreement for services.
I understand that this form is merely an application which requests admittance to the program.
I understand that I must contact the Disability Services Coordinator to schedule accommodations for course placement assessments and that this must be done prior to the scheduled assessment date.
I understand that my disability documentation must be updated every three years. This may require re-evaluation at my own expense.
I understand the Disability Services Coordinator may contact my instructors at any time regarding the accommodations and academic progress.
I understand that I MUST submit a copy of my disability documentation to the Cowley College Disability Services Office before I can receive any accommodations.
I understand that I MUST schedule an appointment with the Disability Services Coordinator to complete a Personalized Plan of Assistance and request my accommodations.
620.441.5557.

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