Accommodation Request Form

Student Information

Please note this submission of this request is not a guaranteed approval of accommodations. Students will be required to meet with staff to discuss accommodation requests to determine approval.

Your application cannot be processed without your Jackson College Student ID and Jackson College Email. To find this information please visit the Jackson College Admissions Page here: https://www.jccmi.edu/admissions/orientation/

First Name

Last Name

Middle Name

Student ID

Please use your Jackson College issued email address. (e.x. ChipsJohnC@my.jccmi.edu)

Phone Number

Preferred Method of Contact

What county do you reside in?

Specific Accommodation Information

My diagnosed disability falls into the following category

How does your disability affect you academically?

Have you applied to live in JC Housing?

What accommodation(s) are you requesting?

Grievance Procedure

Please read our Grievance Procedure before submission of this form.

https://www.jccmi.edu/wp-content/uploads/Americans-With-Disabilities-Act-Grievance-Procedure-Form.pdf?

Accommodations Criteria

Please read our Accommodations Criteria before submission of this form.

https://www.jccmi.edu/center-for-student-success/accommodations-for-students-with-disabilities/#jc-tabs-1-tab-1

Permission to notify Jackson College Employees

Upload supporting document(s)

Verifiable documentation is required; examples of documentation include medical documentation from a licensed medical practitioner, Individual Education Plans, or 504’s. They are used as guidance as some accommodations do not carry over from high school to college.

Accommodation Request Form

Student Information

Specific Accommodation Information

Document Information