Disability Accommodation Request Form for Student Housing

Muscatine Community College recognizes the importance of providing reasonable accommodations in its housing policies and practices where necessary for students with disabilities to use and enjoy college housing. A reasonable accommodation is an exception to the usual rules or policies that a resident with a disability may need to have an equal opportunity to use and enjoy student housing.

Please complete this form and submit it no fewer than 60 days before you intend to move into student housing. Your completed form will be automatically sent to MCC Disability Services once you click "Submit."

If you have any questions about this form, please contact MCC Disability Resources at 563-288-6013 or mccdisabilityresources@eicc.edu.

Asterisk (*) indicates a response is required.

*First Name:
*Last Name:
*EICC Email:
*Phone:
*Specific Reasonable Accommodation being requested:
*Please identify your disability and why you believe the accommodation is necessary because of your disability:
In circumstances where either your disability and/or requested accommodation is not obvious, you must provide a verification from a reliable third-party (e.g., a physician or other medical professional) establishing that you have a disability and that the accommodation is necessary to provide you an equal opportunity to use and enjoy student housing.
Please identify the person that can provide such a verification:
*Name:
*Title:
*Address:
*City:
*State:
*Zip:
*Telephone:
*Your Signature:
*Date:

It is the policy of Eastern Iowa Community College District not to discriminate in its programs, activities, or employment on the basis of race, color, national origin, sex, disability, age, sexual orientation, gender identity, creed, religion, and actual or potential family, parental or marital status, as required by the Iowa Code §§216.6 and 216.9, Titles VI and VII of the Civil Rights Act of 1964 (42 U.S.C. §§ 2000d and 2000e), the Equal Pay Act of 1973 (29 U.S.C. § 206, et seq.), Title IX (Educational Amendments, 20 U.S.C. §§ 1681-1688), Section 504 (Rehabilitation Act of 1973, 29 U.S.C. § 794), and Title II of the Americans with Disabilities Act (42 U.S.C. § 12101, et seq.).

If you have questions or complaints related to compliance with this policy, please contact EICC’s Equal Employment Opportunity Officer/Equity Coordinator, Eastern Iowa Community College District, 101 West Third Street, Davenport, Iowa 52801, 563-336-5222, equity@eicc.edu or the Director of the Office for Civil Rights U.S. Department of Education, John C. Kluczynski Federal Building, 230 S. Dearborn Street, 37th Floor, Chicago, IL 60604-7204, Telephone: (312) 730-1560 Facsimile: (312) 730- 1576, TDD (800) 877-8339 OCR.Chicago@ed.gov.