Complete and submit this form in its entirety. Alternatively, you may print the PDF, complete the form and deliver it to Accessibility Resources.
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:
Mnstate.edu Email Address:
All official University business will be conducted via MSUM email accounts. It is essential that you access, read and use your go.mnstate.edu account.
Current Academic Level:
High School Student
City: State: Zip:
Reason for applying:
I have a disability and I am requesting accommodations
I think I might have a disability
I. Diagnostic Information
Please identify any disability/disabilities that you have been diagnosed with:
List current professionals involved, if applicable:Please provide name, address, and phone number
Psychologist: name, address and phone number
Psychiatrist: name, address and phone number
Family Doctor: name, address and phone number
Other: name, address and phone number
Current disability related medication(s), dosages, and side effects:
Describe your academic skill level in the following areas.
Describe your skill levels in the following areas.
II. Functional Limitations
Functional limitation is a term given to the restriction or lack of ability in performing an action or activity.
Functional Limitations: Please check any of the major life activities listed below that you believe are affected as a result of your diagnosed condition(s). Please indicate level of limitation you believe you experience as a result of the condition.
Current Impact Statement
Describe in as much detail as possible how your disability currently impacts you in regard to the following:
Please describe the accommodation(s) you have received in the past:
Please list the accommodations you are requesting (e.g. adaptive equipment, alternate format, note taking, exam accommodations, sign language interpreter, etc.). Please include the accommodation requested, as well as the reason for that accommodation.
Please identify any other challenges in the school environment you would like to discuss during the intake interview:
Documentation from a qualified professional:
Will be sent via email
Will be sent via fax
Will be sent via regular mail
Will be hand delivered
Has already been submitted
This application for services was completed by:
Other (please specify)
If other, please specify:
If you do not receive confirmation to your email that this form was submitted successfully, please contact the Accessibility Resources Office.