EmailMe Form - COVID: Alternative Educational Arrangement Request

In response to the COVID-19 public health emergency, ABAC will provide an alternative educational arrangement for students who are or might be at an increased risk from COVID-19 as published by the Centers for Disease Control (CDC). A student must fit into a CDC category indicating they are or might be at an increased risk from COVID-19 to be considered for alternative educational arrangements in response to the COVID-19 public health emergency. Approved alternative educational arrangements will end no later than upon the conclusion of the public health emergency as determined by the CDC.

Name *

First MI Last

ABAC ID Number *

Date of Birth *

MM / DD / YYYY

Cell Number

### - ### - ####

Home Phone

### - ### - ####

ABAC Email *

Campus or Site Location *

Student Status *

First-year (beginning) student

Returning Student

Transfer/transient

What CDC published circumstance or underlying medical condition do you have indicating you are or might be at an increased risk for severe illness from the public health emergency? Please see the CDC's current guidance:

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html *

Your Answer

Requested Alternative Educational Arrangements (this list is not all-inclusive, other options may be explored). Request for adaptation of course modality must be received and completed by the end of drop/add for the term requested: *

For some accommodation requests, medical documentation may be required for Alternative Educational Arrangements. After you submit this form, a staff member from Counseling & Accommodation Services will contact you to schedule a phone or virtual meeting to discuss your request for an alternative educational arrangement and documentation requirements. By typing your name, you are confirming that you are the student completing this form. Student signature: *

Your Name