Mars Hill College, in the Blue Ridge Mountains near Asheville, NC

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Mars Hill College Counseling/Disability

Disability Information Release and Accommodation(s) Request

Complete the form below

Today's Date

Asterisks ( * ) indicate required fields.

I wish to declare a documented disability that substantially limits one of more major life activities and makes specific accommodations necessary for me while I am a student at Mars Hill College. Further, I give the Disabilities Coordinator access to my documentation of said disability and permission to seek out further information, if necessary, to certify my accommodation(s) request. I understand that this information will be kept confidential but that information as it relates to my accommodation(s) request may have to be shared on a 'need to know' basis with appropriate individuals.

Student Name
* Last Name	* First Name	Middle Name
Preferred Name	* Gender Male Female	* Semester Accomodations Needed
Contact Information
* Address
* City	State	Zip/Postal Code
Country	Phone	* Email
Personal Information
Diagnosis/Nature of Disability:
Specific Accommodation(s) Requested:
If your disability affects your housing needs, please specify how :
All Mars Hill College students take timed placement tests in reading, writing, math, and in some cases, foreign languages. If your disability necessitates accommodation(s) for these tests which occur before you register for classes, please specify (e.g., extended time, reader, etc.) Appropriate documentation of your disability must be on file at the college. :
Will you receive assistance from the Division of Vocational Rehabilitation, the Division of Services for the Blind or other agencies while you are a student here? Please specify :

revised 9/07

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