Skip to Main Content Skip to Tabs Skip to Sub-Tab Navigation

Sign In

Home

Home
Disability Declaration Form

Disability Declaration Form

Two easy steps to register

Note: All fields with * are required fields.

Personal Information

Start Term *:
Note: Select when you would like to start your services.
Expected Graduation Term:
Note: Select when you plan to graduate.
First Name *:
Last Name *:
Middle Name:
Optional: Preferred Name:
CTC LINK ID:
Hint: Enter 9 alpha numeric characters.
Birth Date *:
Hint: Enter date in the following format Month/Day/Year (i.e. 12/31/2010).
Pronouns:

Contact Information

Cell Phone Number:
Hint: Enter 10-digit number only.
Land Line Phone Number:
Hint: Enter 10-digit number only.
Email Address *:
Hint: Please use your Clark email address if you have one.

Local Address

Address:
City:
State:
Zipcode:
Hint: Enter zipcode as 97331 or 97331-0000.

Questions

Do you attest that you have a disability or health condition and want to request accommodations?

Yes

No

I am not sure

Additional Note or Comment
Have you experienced barriers to getting evaluated of your disability or health impacts?

No access to medical documentation to support the need for accommodation.

No former IEP or 504 plan from HS.

Moved and experiencing challenges to get evaluated.

Cultural/family not supportive of getting a diagnosis.

Or your disability is physical and apparent and you do not think documentation is needed.

Additional Note or Comment

Home
- Online Services Home

Need Help?

Contact Our Office

Disability Support Services

Clark College
1933 Fort Vancouver Way
Vancouver, WA 98663

Website: http://www.clark.edu/dss
Email Us: dss@clark.edu

Phone: (360) 992 - 2314
VP: (360) 991 - 0901

Licensed to Accessible Information Management LLC Copyright © 2010-2024 by Haris Gunadi. All rights reserved.