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Request for Disability Services & Accommodations Form
Home
accessibility resources
Request Services & Accommodations
If you see this don't fill out this input box.
Your Full Name:
*
M Number:
Permanent Address:
Home or Cell Phone:
E-mail Address:
*
Please describe your disability:
*
In your own words, describe how your disability affects you in an academic setting, if applicable.
List the accommodations you are requesting in an academic setting, if applicable.
(e.g., test-taking accommodations, books in alternate format, sign-language interpreters, etc.).
Please describe how your disability affects you in a residential setting, if applicable. (e.g., residence halls, dining halls, athletic centers). List the accommodations you are requesting in a residential setting, if applicable.
(e.g., air conditioning, strobe alarms, wheelchair accessible housing, food allergy).
Describe auxiliary aids, assistive technology and/or services that you anticipate using while attending MVCC, if applicable.
(e.g., service dog, FM system, wheelchair, adaptive technology).
Academic History: High School(s) Attended:
*
List disability accommodations and/or services used there:
Colleges/Universities Attended:
List disability accommodations and/or services used there:
Certification:
I certify that the information provided on this form is accurate. I understand that to be eligible for disability services at MVCC I must (1) submit this completed form, (2) submit disability documentation that substantiates the requested accommodations, and (3) participate in an intake interview with a Disability Services staff person. My signature authorizes DSO to discuss my documentation with the clinician who authored the documentation, if additional information or clarification is required.
Documentation from a licensed professional: is enclosed should be sent separately to
OAR@mvcc.edu
Student’s Signature
*
Date
*
yyyy-mm-dd
Form UUID
Site Name
Submit
Clear
Last Updated 5/11/20