Student Disability Services Registration Form
Sign in to Google to save your progress. Learn more
Today's Date (Date you are completing this Form)
MM
/
DD
/
YYYY
Student Full Name *
Preferred Name
When will you start services with SDS? Please include the semester and year. (ex Fall 2022, Spring 2023, Summer 2024)
M Number
New or Current Student
Clear selection
Classification (Example: Freshman, Sophomore, etc.)
Major and Minor
Gender (Write in your Response)
Race
Ethnicity
Clear selection
Date of Birth *
MM
/
DD
/
YYYY
Permanent Home Address (Street, City, AND State, Zip) *
Local Address (Name of Residential College OR Street, City, State, Zip)
Student Cell Number
Student MSU email
Emergency Contact Information (Name, Relationship)
Emergency Contact phone number and email
What is the nature of your disability? (Check all that apply)
Please describe your disability/medical condition. Specifically, list how it affects your performance as a student and/or how it impacts your daily living:
Which of the following areas are problematic for you? (Check all that apply)
Type of documentation (Check all that apply)
Documentation provider and/or evaluator (Name of High School or Medical Provider/Evaluator)
Date of last disability documentation and/or medical evaluation
MM
/
DD
/
YYYY
Please list what type of accommodations you received in high school.
Please check the accommodation and/or academic support you would like to obtain or learn more about:
Are you a client of Vocational Rehabilitation?
Clear selection
If you are a client of Vocational Rehabilitation, or are awaiting an appointment, who is your counselor?
Exchange of Information/Release Form
In order to explore possible coverage and reasonable accommodations, it is often necessary for the Office of Student Disability Services to discuss the documentation the student has submitted to our office (registration forms, diagnosis, personal requests/statements) with providers such as licensed physicians, psychologists or other qualified professionals and to discuss the student's impairment with the appropriate Murray State University staff.                                                                                    
This authorization will remain in effect for the duration of my enrollment. I understand that I may revoke this release of information at any time by informing the Office of Student Disability Services. I understand that this information is desired in order to assist those who are helping me with my education and request for accommodation, and that my refusal to authorize consent may result in denial of specific accommodations. I also understand that my disability documentation will be kept on file for five years after my graduation or last date of attendance and that I should keep a copy of any records pertaining to my disability.
I hereby give permission for the staff of the Office of Student Disability Services to exchange information regarding the documentation I have submitted with my provider(s) (physician, psychologist, or other qualified professional). Furthermore, I give permission for the staff of Office of Student Disability Services to release and/or obtain information concerning my diagnostic testing, grades, and other information to/from instructors, parents, assigned mentors/tutors, Vocational Rehabilitation counselors, and Murray State University staff as necessary. *
First Floor Housing Information
Kentucky law requires that students who have a disability, or a sensory, cognitive, or neurological deficit or impairment, or a learning disorder, minimal brain dysfunction, dyslexia, pervasive developmental disorder, autism, ASD, or Asperger syndrome be given priority for the first floor housing assignments. If you have a disability or condition, as noted above, and desire a first floor housing assignment, contact the Associate Director for Administrative Services at the Murray State University Housing Office, phone number 270-809-2310, to request a “Housing Request Re: First Floor Housing Assignment.” Please note that first floor housing assignments are only available in Lee Clark, HC Franklin and Richmond Colleges.
Clear selection
Student Signature and M Number *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Murray State University. Report Abuse
Google Forms