Online Student Application

Questions

1. Current Employment
2. Hours per week at Current Employment
3. Secondary School(s) Academic History: please list all schools, date of attendance, and disability related services used.
4. College/University(ies) Academic History: please list all schools, dates of attendance, and disability related services used.
5. Physician's and/or Therapist's Name and Address:
6. Date of diagnosis:
7. Medications (please list all medications you are currently taking):
8.  

   I understand that in order for the DSS office to verify my disability DSS must obtain pertinent student evaluations, psychological reports, transcripts, and medical reports. I understand that no one other than DSS personnel has immediate access to my DSS files, and that any information regarding my disability shall be considered confidential and will only be shared with on a need-to-know basis. * (Selection is Required)

   Agree

   Additional Note or Comment
9. If your disability impairs notes, describe your specific difficulty when taking notes.
10. If your disability impairs reading textbooks, describe your specific difficulty when reading textbooks.
11. If your disability impairs taking tests, describe your specific difficulty when taking tests.
12. Describe your interests and strengths outside the classroom (example, what extra-curricular activities do you enjoy and perform well?).
13. Describe your professional/career goals.
14. What accommodations are you requesting?
15. Describe your comfort level with your discussing your disability with MSU faculty and staff members.
16.  

    How did you learn about DSS services?

    ADA statement on course syllabus

    Adult rehabilitation agency

    Another student

    College instructor

    College staff

    High school

    College catalog/course schedule

    Parent

    Self

    Website

    Other (Specify Below)

    Additional Note or Comment
17. Emergency Contact (please include relationship, address, phone, and email):
18.  

    What is the best way to contact you?

    Email

    Cell Phone

    Home Phone

    Other (Specify Below)

    Additional Note or Comment