subject_line
Request for COVID-19 Academic Adjustment
First Name
*
Middle Initial
Last Name
*
Student ID Number
*
Highland Email Address
*
Cell Phone Number
*
Preferred Pronouns
He, Him, His
She, Her, Hers
They, Them, Theirs
Other (Please Specify)
Other (Please Specify)
Location
*
Highland Campus
HCC Online
Perry Center
Technical Center (Atchison)
Wamego Center
Western Center (Baileyville)
Reason for Request
*
Quarantine
Isolation
International Late Arrival
Compromised Immune System in Household
Personal Health
Other (Please Specify)
Other (Please Specify)
If you selected Quarantine, have you heard from Public Health or a medical provider?
*
Yes
No
If you selected Isolation, please specify when you tested positive
*
+
Please describe the circumstances preventing you from attending face-to-face classes and requiring you to need an alternative delivery method. Additional documentation may be required during review. Please provide your release date if you have one.
*
Please upload any supporting documentation (Test result, public health order, doctor's note, etc.).
I attest that the above information is factual
*
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