Date

Semester for Request

Fall Spring Summer

Semester Year

ex. 2006

Student Name

Student ID

ex. 111-22-3333

Date of Birth

ex. 1-12-1980

Address

City

State

Zip Code

Home Phone

ex. 417-555-1234

Work Phone

ex. 417-555-1234

Alternate Phone

ex. 417-555-1234

Email Address

ex. name@missouristate.edu

Referred By

Class Status

Freshman Sophomore Junior Senior Graduate Continuing Education

Major

Would you like to register to vote?

No Yes

Nature of Disability

Acquired Brain Injury ADD/ADHD Blind Chemical Dependence Deaf Deaf/Blind Hard of Hearing Health Related Language Learning Low Vision Orthopedic Psychological Speech Other

If you selected OTHER in the Nature of Disability menu, please explain here.

Type of Accommodations Requested (check all that apply)

Priority Registration
Large Print
Braille
Textbooks in Alternative Format
Out of Class Testing
Extended Time on Tests
Distraction Reduced Testing
No Scan-Tron for Testing
Spelling Accommodation
Alternative Formatted Tests
Hand Rails
Assistive Technology
Low Vision Aids (not provided by university)
Assistive Listening Device
Closed Captioning (videos)
CART
Adapted Computer
Spell Checker (not provided by university)
Tape Recorder (not provided by university)
Space for Wheelchair
Adjustable Tables
Accessible Parking
Accessible Site
Special Seating
Preferential Seating
Service Animal (not provided by university)
Lab Assistant
Note-Taker
Captioning
Interpreter
Scribe
Reader
Calculator (not provided by university)
Disability Related Absence
Personal Care Attendant (not provided by university)
Roll-In Shower
Bathtub with Shower
Flashing Doorbell/Fire Alarm
Shower Seat
Other (explain below)

Other

By entering your name in the box provided, you agree that all information presented on this form is accurate