The University of Missouri- Rolla (Missouri S&T) is committed to providing quality education for all individuals.

If you have a permanent or temporary disabling condition that may require special attention or services,

please complete this form. Doing so is voluntary, and all information will be kept confidential.

Information about Disability Support Services and the required disability documentation, will be sent to

individuals who complete this form and anyone else who requests the information.

Name:____________________________________________________

            ^{Last                                 First                                    Middle}

Email:____________________________________________

Address:_____________________________________________________________________

                ^{Street Address                                     City                             State                Zip Code}

Missouri S&T Student Number__________________________________

Phone Number: (_____)___________________

I will be enrolled at Missouri S&T for the ____Fall _____Winter ____Summer 200____ semester

Freshman: _______ Transfer: ________ Graduate: ________

I am currently enrolled at Missouri S&T :_______

Type(s) of disability: ___Mobility ____ Visual ____Hearing ____ Learning Disability ____AD/HD

Other:

Are you receiving State Vocational Rehabilitation Agency services? ____Yes ____No

Comments:

Please print and complete this form. Mail to the address listed below:

Connie Arthur

Advisor, Disability Support Services Telephone:(573) 341-4211

Missouri University of Science and Technology TTY: (573) 341-6645

203D Norwood Hall Fax: (573) 341-6179

1870 Miner circle Email: conniea@mst.edu

Rolla, MO 65409- 0950