Student Services
Menu
Disabilities Services
712.274.8733 ext. 3216
Michelle.Fiechtner@witcc.edu
Contact Information
Disabilities Services
712.274.8733 ext. 3216
Michelle.Fiechtner@witcc.edu

Request for Accommodations

Western Iowa Tech Community College
Student Request for Reasonable Accommodation Form

Items with an * are required.

This form should be completed when a student has indicated his or her desire to request a reasonable accommodation from the College. Upon completion, this form must be delivered to the office of the Special Needs Coordinator and kept separate from the student's general enrollment file.

The purpose of this form is to assist the College in determining to what extent a reasonable accommodation is required to assist an applicant or student to be considered for admission to a program, course, or activity; to meet and perform the academic and technical standards requisite of an education program or activity; or to enjoy equal benefits and privileges of education as are enjoyed by other similarly situation applicants and students without disabilities.

TO BE COMPLETED BY THE APPLICANT OR STUDENT

  1. , illness, condition, or disease which is the basis for your request for reasonable accommodation(s) by the College. Students must provide appropriate documentation of any diagnostic evaluations, including medical records (when appropriate), to establish the existence of a claimed physical, mental or learning impairment. (Please attach below or email to the Special Needs Coordinator.)
    (pdf files only)

I hereby authorize the above-listed providers and any others who have treated me to release to Western Iowa Tech Community College all academic/medical records concerning the disability disclosed herein and to provide any opinions to the College concerning my ability to: 1) be considered for admission to my desired program, course or activity; 2) meet and perform the academic and technical standards requisite to performance of the education program or activity that is the subject of this request; or 3) enjoy equal benefits and privileges of education as are enjoyed by other similarly situated applicants or students without disabilities.

I certify that the foregoing statements are complete, accurate, and true to the best of my knowledge. I also understand the College may require me to undergo testing or evaluation by medical personnel for the purpose of establishing the existence and extend of my disability, illness, condition, or disease and my need for a reasonable accommodation, if any.

Take the Next Step
Visit at 4647 Stone Avenue, Sioux City, Iowa 51106
4647 Stone Avenue
Sioux City, Iowa 51106
Call 800.349.4649 or 712.274.6400
800.352.4649
712.274.6400
Email info@witcc.edu
info@witcc.edu