Southeastern Community College

Student Intake Form

* denotes required information.

Student Information

* First Name:

* Last Name:

* Social Security Number:

* Street:

* City:

* State:

* Zip:

* Date of Birth:  Please enter as mmddyyyy, and enter only numeric digits. Example 01022003

* Home Phone:  Please include area code, and enter only numeric digits. Example 3197522731

Alternate Phone:  Please include area code, and enter only numeric digits. Example 3197522731


* Email:

Medical/Emergency Information

* Emergency Contact:

* Relationship:

* Emergency Phone:  Please include area code, and enter only numeric digits. Example 3197522731


Educational Goal (check all that apply):
  Certificate Subject:

* Campus you will attend:

* When will you start classes?  Term:    Year: 

Medical Background

What is your diagnosed disability?

How does your disability affect, limit, or impact you as a student (2400 characters or less)?

List any medications you are taking and describe the side effects that may empact your performance in the classroom (2400 characters or less):

Which of the following categories best describes your disability (check all that apply)?
 Attention Deficit Disorder (ADD)/Attention Deficit Hyperactivity Disorder (ADHD)
 Blind/Visual Impairment
 Brain Injury
 Chronic Illness
 Deaf/Hard of Hearing (HOH)
 Learning Disability (LD)
 Mental Health Impairment
 Mobility Impairment
 Speech Impairment
Other Disability:

Support Services

Have you ever received help from any outside agency for academic, career, or personal counseling? If yes, please name the agency and the nature of the services received. (2400 characters or less):

Did you receive support from Disability Services at any high school, college, or university you have attended? If yes, please list. (2400 characters or less):

Did you receive Vocational Rehabilitation Services? If yes, please list counselors name. (2400 characters or less):

What testing accommodations are you requesting? (i.e., testing in SuCCess Center, sign language interpreter, note taker, use of assistive technology)
Note: Actual accommodations are dependent upon appropriate documentation. (2400 characters or less):

As a student eligible for accommodations through Disability Services, per the Rehabilitation Act of 1973, Section 504, and the Americans with Disabilities Act of 1990, I understand that I also have certain responsibilities. I will do my part in meeting these responsibilities so that appropriate accommodations may be arranged.

  • Provide appropriate documentation to support the accommodations requested.
  • Understand that accommodations must be requested in a timely fashion to obtain the most appropriate accommodation available.
  • Fill out an Accommodation Request Form each semester that I desire accommodations.
  • Notify Disability Services of changes in my schedule as soon as I know about them. Failure to do so may result in a delay of accommodations.
  • Schedule an appointment with the Disability Services Coordinator if I have any concerns or questions related to my accommodation(s).

Information contained within the file will be kept confidential and will not be shared with anyone outside SCC without your expressed authorization.

I understand that entering my name constitutes a legal signature confirming that I acknowledge and agree to the above responsibilties.

* Student Name:

It is the policy of the Southeastern Community College not to discriminate on the basis of race, color, national origin, sex, disability, age, employment, sexual orientation, gender identity, creed, religion, and actual or potential family, parental, or marital status in its program, activities, or employment practices.

If you have questions or complaints related to compliance with this policy, please contact Tina Young, Title IX & Equity Coordinator, 1500 West Agency Road, West Burlington, Iowa 52655, 319-208-5101,, fax number 319-208-5005 or the Director of the Office for Civil Rights U.S. Department of Education, Citigroup Center, 500 W. Madison Street, Suite 1475, Chicago, IL 60661-7204, Telephone: (312) 730-1560 Facsimile: (312) 730-1576, Email: