Request for Disability Services & Accommodations Form

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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