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  • Application for Services

Disability Services

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  • Application for Services

    Complete and submit this form in its entirety.

    I have reviewed the Rights and Responsibilities. My electronic signature on this form signifies I have read and agree to my Rights and Responsibilities. Type your full legal name  

    Name:
    Dragon ID:
    Email:
    Phone:

    Can we call you if necessary?

    May we leave a message?

    Birthday:
    Gender:

    Current Academic Level:

    Local Address

    Street:
    City:
    State:
    Zip:

    Permanent Address:

    Street:
    City:
    State:
    Zip:

    Emergency Contact

    Name:
    Phone:

    Disabilities

    Please write a 1 next to your primary disability and a 2 by any additional disabilities below:

    Acquired/Traumatic Brain Injury:
    ADHD/ADD:
    Autism Spectrum Disorder:
    Blind/Vision:
    Chronic Medical Condition/Physical Disability:
    Deaf/Hard of Hearing:
    Learning Disability:
    Psychiatric/Psychological:
    Temporary Medical Condition:
    Other (please describe):

    Current Impact Statement

    Describe in as much detail as possible how the diagnosed condition is currently impacting and limiting your ability to learn.
     

    Accommodations

    If eligible, what accommodations are you requesting?

                   

    Please Describe:

    Did you receive any type of special services in high school?
    If yes, please describe:  

    Did you receive any type of special services at a previous college?
    If yes, please describe:

    Agency Affiliation:

                  

    Please Describe:

    Complete and submit this form to Disability Services. Please remember to include documentation of your disability with your application. Your application for services will not be processed without required documentation as outlined under the Documentation Guidelines.

    The application and documentation can be submitted in person to Disability Services, Flora Frick 154, submitted via email, or faxed to 218.477.2420. Once your application and documentation have been processed, you will be contacted via email to set up an appointment to discuss your accommodation needs.

    If you are unable to complete this form due to your disability, please contact Greg Toutges, Director of Disability Services at 218.477.4318 and assistance will be arranged.

    Please allow time for your submission to process after you click "Submit Form". This will prevent multiple submission from being made.