New Submission

STUDENT ACCESSIBILITY RESOURCES (SAR)
Student Request Form

Todays Date*field type date
TCC ID #field type single line
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Student's First Name*field type single line
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Student's Last Name*field type single line
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Preferred Name/Pronounsfield type single line
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Phone Number:*field type single line
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Email*field type email
if available please use your @my.tccd.edu email address

1. How did you hear about the Student Accessibility Resources department?field type checkbox
1. How did you hear about the Student Accessibility Resources department?Campus ReferralHigh School CounselorFamily/FriendInstructorPoster/AdvertisementWebsiteOther

	Namefield type single line	Relationshipfield type single line	Phone Numberfield type single line
2. Emergency Contact Information (optional)	Namefield type single line Input blocked. Maximum character limit of 4000 characters reached.	Relationshipfield type single line Input blocked. Maximum character limit of 4000 characters reached.	Phone Numberfield type single line Input blocked. Maximum character limit of 4000 characters reached.

3. Are you attending high school?field type radio button
3. Are you attending high school?YesNo
If yes, please select one:field type radio button
If yes, please select one:Dual CreditEarly College High School
4. Do you give permission to leave confidential information on voicemail?*field type radio button
4. Do you give permission to leave confidential information on voicemail?YesNo
5. Are you currently enrolled at TCC?*field type radio button
5. Are you currently enrolled at TCC?YesNo
5-B. Which do you consider your home campus?*field type radio button
5-B. Which do you consider your home campus?NortheastNorthwestSouthSoutheastTrinity RiverTCC ConnectNorthwest Center of Excellence for Aviation, Transportation and Logistics (CEATL)
5-B. What semester are you planning to start TCC?*field type radio button
5-B. What semester are you planning to start TCC?FallSpringSummerNone, currently exploring colleges
5-C. Which campus do you plan on attending?*field type radio button
5-C. Which campus do you plan on attending?NortheastNorthwestSouthSoutheastTrinity RiverTCC Connect
6. Have you previously received Student Accessibility Resources services at TCC?*field type radio button
6. Have you previously received Student Accessibility Resources services at TCC?YesNo
7. Have you received accommodations at another college?*field type radio button
7. Have you received accommodations at another college?YesNo
If yes, please list accommodations you received:field type multi line
8. Are you requesting services for orientation and/or placement testing (TSI)?*field type radio button
8. Are you requesting services for orientation and/or placement testing (TSI)?YesNo
If yes, please state the accommodations you are requesting:field type multi line
*Please note that some accommodations may require additional time to arrange once approved.
Do you need interpreting or CART services for your intake appointment?*field type radio button
Do you need interpreting or CART services for your intake appointment?YesNo
9. Are you a veteran?field type radio button
9. Are you a veteran?YesNo
10. Are you currently working with any of the following agencies?field type checkbox
10. Are you currently working with any of the following agencies?Texas Workforce Solutions VR (previously known as DARS)MHMR Mental Healtlh ServicesOther

10-B. If so, please include your casework's/counselor's information

Namefield type single line
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Phonefield type single line
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Emailfield type single line
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11. Disability Information: Check all that apply.*field type checkbox
11. Disability Information: Check all that apply.ADHDAutism SpectrumBlind/Low VisionChronic MedicalDeaf/Hard of HearingTraumatic Brain InjuryLearning DisabilityMental HealthPhysical/MobilityUnknownOther
11-B. Carefully read the Documentation Guidelines to determine what documents are required to assist in establishing appropriate accommodations. The SAR office of your home campus will have access to the files you submit and are confidential under FERPA guidelines.
Please upload documentation of disabilityfield type file upload
Drop files here
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Accommodations-Please list what accommodations you are requesting:*field type multi line
(Accommodations will be determined during intake)
Signature*field type signature