Disability Services Form
Community College in the High School Program (CCHSP)

Please sign below indicating your choice to self-disclose or not to self-disclose for your CCHSP course(s).  You must sign in one of the two boxes.  Please return this form to your high school guidance counselor as soon as possible. It is recommended that it be returned at least one month prior to the beginning of class.

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 the CCHSP Coordinator and the Office of Disability Services at SUNY Orange.  I understand that my high school guidance counselor will give a copy of this form, as well as, a list of my accommodations and/or modifications to my instructor(s).  However, it is ultimately my responsibility to self-advocate and make sure that my instructor(s) have been notified of my choice to self-disclose and that they are aware of the accommodations and/or modifications I receive. 

I understand that accommodations and/or modifications provided at the college level may not alter the fundamental requirements of the course.  For example, �un-timed tests� are not permitted, instead 1.5 or twice as long is usually indicated; generally, assignment extensions are only allowed at the instructor�s discretion.  Questions concerning modifications that may alter the rigor of a course are to be directed to the CCHSP Coordinator at SUNY Orange, (845) 341-4179.

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



I choose not to receive disability services for my CCHSP course(s).  

My choice not 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, who will notify SUNY Orange.

__________________________________________________________      _____________________________
		Student�s Signature							Date


Instructions for Guidance:  If the student self-discloses, please send the completed copy of this form to: 

       CCHSP Coordinator
       Office of Educational Partnerships
       SUNY Orange
       115 South Street
      Middletown, NY 10940