Accessibility Services Form

Community College in the High School Program (CCHS)

Please sign below indicating your choice to self-disclose for your CCHS course(s).  Please return this 
form to your high school guidance counselor as soon as possible.


I choose to self-disclose and receive accommodations and/or modifications consistent with my disability.  
I agree to have my disability documentation released, when necessary for review, from my high school to 
Nancy Boylan (nancy.boylan@sunyorange.edu or 845-341-4760) and the Office of Disability Services at 
SUNY Orange.  I understand that my high school guidance counselor will give a copy of this form and a 
list of the accommodations and/or modifications recommended/approved by SUNY Orange to my 
instructor(s).

I understand that accommodations and/or modifications provided for college-level courses may not alter 
the fundamental requirements of the course. Questions concerning modifications that may alter the rigor 
of a course are to be directed to Nancy Boylan (nancy.boylan@sunyorange.edu or 845-341-4760).

My choice to self-disclose shall remain in effect for the __________________ academic year, but I may 
revoke it at any time, in writing, by contacting my high school guidance counselor.

_________________________________________________________   __________________________
Student�s Signature							    Date

__________________________________________________________	__________________________
Parent�s Signature							     Date

____________________________________________________________________________________
Student�s Address



Instructions for Guidance:  If the student self-discloses, please send the completed copy of this form, 
the student�s IEP and a list of accommodations and/or modifications to: 

       Nancy Boylan, Lead Director
       Office of Educational Partnerships
       SUNY Orange
       115 South Street
       Middletown, NY 10940
       Phone: 845-341-4760
       nancy.boylan@sunyorange.edu