Access / Disability Services - Student Information Intake Form

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Your Information

Full Name

CCA ID

If you do not know your ID#, please enter 0000000 (7 zeros)

Email address

Phone number

Birth Date

CCA Student Status

Disability and Accommodations

Describe your disability

Please describe your disability and how it affects you as a student (in your own words). Please note that you will also be required to provide documentation of your disability signed by a licensed clinician, learning specialist or other qualified diagnostic professional.

Accommodations / Assistance

What types of accommodations and/or assistance are you interested in receiving?

Upload Documentation

Please attach your documentation of your disability here (please note your documentation should meet CCA's documentation guidelines, found on on Access/Disability Services on portal.cca.edu).

You can upload up to three files - to upload more than three files, please add them to a single zip file before uploading.

Upload documentation (Maximum file size 10mb)

Fields for form variables

Contact Information