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Roane State Community College

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Move Forward. Don't delay your future! Apply now! Register for online or traditional classes.Move Forward. Don't delay your future! Apply now!. Register for online or traditional classes.
Tennessee Reconnect and Promise. Graduating high school seniors can attend tuition-free. Free tuition for adults.Tennessee Reconnect and Promise. Graduating high school seniors can attend tuition-free. Free tuition for adults.
Online degrees available. Choose from six completely online programs.Online degrees available. Choose from six completely online programs.

Roane State Disability Services Information Form

Please complete this form by typing below and printing and signing, or by printing and completing in Black Ink and signing. Then submit this form with appropriate documentation directly to Disability Services (fax 865-481-2009 or scan and email to accommodations@roanestate.edu). The student must notify Disability Services directly of any demographic changes, including name, phone, email, and/or address changes.

Please Note: complete section below only if you want Disability Services to be able to communicate with the person(s) listed. If not, leave below blank.

Please Note: complete section below only if you want Disability Services to be able to communicate with the person(s) listed. If not, leave below blank.

What is the nature of your disability? (Please check all that apply below or list other.)

Limited major life activity: (Please check all that apply.)

Agreement and Signature

By signing this completed form, I am giving the Disability Services staff permission to discuss my case with the person(s) listed above. I understand it is my right and responsibility at any time, as the student, to change or cancel this release by providing written notification of the change(s) to Disability Services, as well as by filling out a new Disability Services Information Form.

I have thoroughly read and understand the Roane State Community College Disability Services Handbook. I agree to abide by these guidelines and procedures. I understand that the handbook may be revised at any time without notice, and the most up to date version is located on the Disability Services website at www.roanestate.edu/disabilityservices. I give Disability Services permission to discuss my case with Disability Services staff, faculty, Testing Center staff, Learning Center Staff, other Roane State staff, and outside agencies as needed in order to coordinate accommodations and disability services. I also understand that the specific accommodations that I request above are not guaranteed, but reasonable accommodations will be determined when I meet at the Accommodation Appointment which I schedule each semester with Disability Services on a case-by-case basis. Email Disability Services accommodations@roanestate.edu to schedule an appointment or with questions.

Contact: 

Tina Messamore • (865) 354-3000 ext. 4716 • Click name for email address

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Roane State Community College does not discriminate on the basis of race, color, religion, creed, ethnicity or national origin, sex, disability, age, status as protected veteran or any other class protected by Federal or State laws and regulation and by Tennessee board of Regents policies with respect to employment, programs, and activities.​​​​​​​ View full non-discrimination policy.

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