Public Accommodation Request

Are you currently attending ESCC?Required *

Are you currently attending ESCC? Yes Are you currently attending ESCC? No

Do you plan to transfer?Required *

Do you plan to transfer? Yes Do you plan to transfer? No

Are you currently employed?Required *

Are you currently employed? Yes Are you currently employed? No

Educational Goals:Required *

Please check all that apply

Take a few courses that interest me Complete a certificate at ESCC Complete a 2-year applied science degree at ESCC Complete a 2-year transfer degree at ESCC and transfer to a four-year college Take transfer classes and transfer after one year Improve basic skills in reading, writing, math, etc. Other

Have you registered to vote?

Have you registered to vote? Yes Have you registered to vote? No

Disability Information Required *

Check all that apply

Blind/Visually Impaired Deaf or Hard of Hearing Mobility Impairment Brain Injury Cerebral Palsy Learning Disability Speech Impairment Other

Please check any services you received in high school or college

Check all that apply

Speech therapy Vision training or prism lenses Certification for books on tape Large print textbooks Braille textbooks Medication for ADHD Psychotherapy Sign language interpreter Personal assistant

Please check any accommodations you received in high school or college

Use of tape recorder Extended time on tests or assignments Provision of private testing room Special seating arrangement Special chair or desk/table requirements Special lighting Adaptive technology Other

Are you a client with any Virginia State Agency?Required *

(DRS, DBVI, VDDHH, Mental Health)

Are you a client with any Virginia State Agency? Yes Are you a client with any Virginia State Agency? No