DISABILITY DOCUMENTATION FORM FOR STUDENTS

WITH MOBILITY IMPAIRMENTS AND OTHER FUNCTIONAL IMPAIRMENTS DUE TO MEDICAL CONDITIONS

Date:______________________ Name of Student:_________________________________

I grant permission for my medical provider to release (copies of) information regarding my disability, the diagnosis, treatment and accommodation recommendations to the Office of Disabled Student Services at Lake City Community College.

Signature _______________________________________________

Dear Medical Professional:

The student whose name appears above has applied for services from the Disabled Students' Services (DSS) at Lake City Community College. In order for DSS to establish whether this student has a disability and to determine her/his eligibility for services, we will need your assessment and diagnosis of this student. A disability is defined as a physical or mental impairment that limits one or more major life activities such as those delineated below. You can fax or mail the form to us at the address in our letterhead. If you prefer, you can answer these questions in a signed and dated letter on your professional letterhead.

1. What is the diagnosis/impairment:  

2. Date of diagnosis / impairment:_________________________________

3. Is the patient / student currently under your care?____________________

4. When did you last see the patient / student?:_____________________________