Title IX Accommodation Request

NTC - Disability Services

TITLE IX ACCOMMODATION REQUEST FORM

Name*

First Name

Last Name

Student ID Number*

Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Email*

Phone*

Program / Class*

Accommodations requested*

Please include dates of classes, assignments, and tests affected.

Why do you need the requested accommodation(s)?*

How will you submit your documentation?*

Mail to DS Office, NTC, 1000 W Campus Dr, Wausau, Wi 54401 Hand deliver to the Wausau campus Disability Services office, room C163 Email DS@ntc.edu Fax 715.301.2469 Upload files

Title IX Documentation*

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Do you need another file?

Yes No

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I give permission for the staff of NTC Disability Services to discuss my educational accommodation needs with the faculty, staff, counselors, and Deans of the program/class I am applying for accommodations in and for the medical professional providing the documentation that I have submitted in order to determine reasonable accommodations.

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Please enter your initials in leu of a signature*

Student Signature*

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Date*

Disability Services

Disability Services Staff Signature*

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Date

NTC - Disability Services

Disability Services

Disability Services

715-803-1469

DS@ntc.edu