Public Accommodation Request

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Student Information

Please enter your information. The information you provide is confidential.

First Name

Last Name

Middle Name

Student ID

Enter your college ID, if you are not enrolled please enter your phone number

Please provide the email address we can use to contact you.

Phone Number

###-###-####

Specific Accommodation Information

My diagnosed disability falls into the following category

How does your disability impact you?

What is your preferred campus for Accommodations Specialist meetings?

What accommodations have you used in the past?

What are your anticipated accommodation needs?

Have you had previous contact with MPTC Disability Resources

Upload supporting document(s)

Confidentiality Statement

By submitting this form, I acknowledge that: (1) I have filled out this form with accurate information; (2) this application will not be processed until pertinent documentation of disability has also been provided; (3) the Accommodation Specialist will consider the accommodations as requested on this form; (4) accommodations, if rendered, may not be the same as those I received in high school or at another institution, and will not apply retroactively; (5) notification will be sent upon completion of the accommodation determination process; (6) Disability Resources will not disclose confidential information obtained from the discloser to anyone unless required to do so by law or an authorization to release confidential information has been signed.