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

Please sign below indicating your choice to self-disclose for your CCHSP 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 
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 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 the SUNY Orange CCHSP Coordinator at (845) 772-1229 or 
mary.ford@sunyorange.edu.

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: 

      Mary Ford
      Office of Educational Partnerships
      SUNY Orange
      115 South Street
      Middletown, NY 10940
      Phone: (845) 772-1229
      Fax: (845) 341-4382
      mary.ford@sunyorange.edu