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Request for Disability Services & Accommodations Form
Home
accessibility resources
Requesting Accommodation
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 Office of Accessibility Resources (OAR) to discuss my documentation with the clinician who authored the documentation if additional information or clarification is required. In order to qualify for accommodations in postsecondary settings, students must self-identify as having a disability to the Office of Accessibility Resources. Completing this form is the first step of the process to become registered with the OAR, which establishes the need for accommodations. Staff will then email you to set up additional meetings to discuss the process and engage with the student in the interactive process to determine reasonable accommodations. Please email
oar@mvcc.edu
if you have any questions.
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 9/27/24