Students: To receive accommodations and services from Services for Students With Disabilities complete and current documentation must be on file. Download, print and complete copies of this form and give it to any providers (doctor, psychologist, school, etc.) from whom you request documentation. The provider may then send the documentation to the address below or you may send the documentation to our office. A copy of this completed form should be included with any documentation sent to this office so that it is included in the proper file.
Please note: It is the student's responsibility to provide documentation of his/her disability in order to receive accommodations. Any costs for obtaining the information are the student's responsibility.
Name ______________________________ Social Security No. _____________________
Address _______________________________________________________
City ______________________________ State _____ Zip _________________
Phone/TTY ________________________
I, ____________________________________, release a copy of all necessary records, including testing, evaluation, etc. to Pellissippi State Technical Community College for the purpose of providing supportive services to me while enrolled as a student. I also give permission for the disability office to contact the provider listed below. The student, upon written notification to Services for Students with Disabilities, can cancel this release at any time.
Student Signature _________________________________ Date ________________
Please complete the following information and submit the form(s) to the agencies or persons who will provide the documentation of your disability. You must submit a separate form to each provider.
Name of Provider _____________________________________________
Address _____________________________________________________
City ________________________________ State ______ Zip ____________
Telephone ________________________ Fax _____________________
Disability documentation and a copy of this completed form should be sent to:
Pellissippi State Technical Community College - Services for Students With Disabilities
10915 Hardin Valley Rd ~ P.O. Box 22990 ~ Knoxville, TN 37933-0990