Student Disability Services

University of Mississippi

The University of Mississippi

Office of Student Disability Services


Student Request for Reasonable


Intake Application

Date_____/_____/_____ UM ID#:_________________


Personal Information


Student’s Name:________________________________________________________________

(First)   (Middle)   (Last)


Date of Birth ___/___/___    Gender: ___Female ___Male


Mailing Address: ________________________________________________________________

(P.O. Box or House Number)             (Street Name)



(City)                                                  (State)                             (Zip code)


Student Phone #: ______________________   Home Phone #:    __________________________




Disability Related Information  (THIS SECTION MUST BE COMPLETED FULLY)

Disability Category (please check all that apply):


 Specific Learning Disability  ADD/ADHD

 Mobility  Other Physical

 Blind/Low Vision  Deaf/Hard of Hearing

 Psychological  Chronic Illness

 Neurological  Temporary Injury


Specific Diagnosis/(es):_____________________________________________________________


Specific Accommodations Requested (Accommodations Requested MUST be included):



Type of Documentation Submitted: ____________________________________________________


Academic Information


Are you admitted to the University of Mississippi? _________   Academic Status (please check one):


 Incoming Freshman/Transfer (Anticipated  Junior

date of enrollment) ____/____/____  Senior

 Freshman  Graduate

 Sophomore  Law


Verification Information


It may be necessary to contact a student’s parents, legal guardian and/or health care professional during the verification process.  Please indicate below whom we may contact on your behalf:


You may contact my parents or legal guardian

You may contact my healthcare profession

Do not contact anyone on my behalf


By signing below I am acknowledging that I am allowing or not allowing SDS to contact those listed above.  I understand that this permission extends to the verification process only.


_________________________________________________________ ____________

(Student’s Signature)                                                          (Date)


Disclosure Information


By completing and signing this intake application, the signer is voluntarily disclosing a disorder and requesting accommodations.  Disclosure of a disorder at this time does not necessarily confirm eligibility status for services or accommodations.  While the Office of Student Disability Service will make every attempt to quickly review all requests for accommodations, the verification process may take several weeks or longer, depending upon the comprehensiveness and currency of the documentation submitted.


All information submitted to this office is to be completely confidential and used only for the purposes of verification and in connection with this institution’s commitment and obligation to students with disabilities.


By signing below, you confirm that you have read (or have had read to you) and understand this document.


_________________________________________________________ ____________

(Student’s Signature)                                                               (Date)


_________________________________________________________ ____________

(Staff Member Signature)     (Date}

University of Mississippi

Student Disability Services

Intake Application PAGE   * MERGEFORMAT 2 Revised November 2012



Office Use Only

Date  ______________

UM ID#_______________