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Harrisburg Area Community College Student Access Services Referral Form
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Student Information
Please enter your information. Please note that the college will be closed December 23, 2025 through January 4,2026. We will respond to your request as soon as possible. Thank you.
Student's Legal First Name
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Student's Preferred First Name
Student's Last Name
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Student's Middle Name
Student's HACC Email
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Student's HACC ID number
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The HACC ID starts with an "H" Zero.
Student's Phone Number
I am a HACC student or future HACC Student
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I am a HACC student or future HACC Student
Yes
I am a HACC student or future HACC Student
No
I am referring a current HACC student
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I am referring a current HACC student
Yes
I am referring a current HACC student
No
Additional Information
Birthdate
I am a Veteran
I am a Veteran
Yes
I am a Veteran
No
Primary Disability
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ADD/ ADHD
Autism Spectrum
Learning Difficulty
Hearing Impairment
Medical such as: Migraines, Lupus, etc
Mobility
Psychological such as: Anxiety, Depression, PTSD, Bi-Polar
Vision Impairment
Other
Pregnancy or related condition
Are there other diagnoses that impact you in the classroom ?
ADD/ ADHD
Autism Spectrum
Learning Difficulty
Hearing Impairment
Medical such as: Migraines, Lupus, etc
Mobility
Psychological such as: Anxiety, Depression, PTSD, Bi-Polar
Vision Impairment
Other
Pregnancy or related condition
How does your disability impact you in the classroom? Please check all that apply.
Required
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Getting distracted while taking tests
Having enough time to complete tests
Having to miss class due to symptoms
Reading information in class or on tests
Reading textbooks
Taking notes during class
Other
Types of Disability Documentation
To receive accommodations through Student Access Services students must present documentation verifying their disability. If you have documentation you would like to upload now, please check the type of documentation you are uploading.
An IEP or a 504 Plan from 11th or 12th grade
A note from a Doctor. On letter head, listing diagnosis and impact of diagnosis.
A copy of a psychological evaluation
An Audiologist Report
I need help identifying what I could use as documentation
Email Address of individual completing this form:
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I am referring the HACC student for the following reasons:
TITLE IX : Referring student for Title IX Pregnancy and Parenting supports and accommodations. Student disclosed pregnancy, related condition or a parenting concern which is disrupting their learning and participation.
ADA/504/508: Referring student for ADA accommodations. Student disclosed diagnosis or condition impacting their ability to fully participate and/or demonstrate their knowledge.
Additional information:
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Upload supporting document(s)
Add Item
Thank you for completing our public request form.
Please keep in mind, Student Access Services strives to meet with students within two weeks of submission of documentation, depending on the volume of submissions. It is recommended that documentation be submitted well in advance of any accommodation related needs, so that we can ensure adequate processing time.
Document Information
Document Title
File
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Maximum file size: 10240kb
Description