DISABILITY SERVICES - DOC

							                                     DISABILITY SERVICES
                             Department of Counseling and Career Services
                                       Edison Hall, Room 100

                                               732-906-2546

                                DISABILITY SERVICES APPLICATION

This application is a request for disability services from Middlesex County College. Students seeking
disability services must provide appropriate documentation. The College reserves the right to request
additional documentation. Students are advised to familiarize themselves with the full Disability Services
Policies and Procedures (available in the Disability Services Office, ED 100).

Please note: This is not an admissions application to Middlesex County College. An application for admission
to the College must be submitted to the College’s Admission Office in Chambers Hall or online at:
www.middlesexcc.edu.

Name: _____________________________ Address: ______________________________________________

Telephone: Home (_ _ ) ______________ Work ( __)_________________ Cell (
__)____________________

Email: ____________________________

Describe your disability: ____________________________________________________________________

__________________________________________________________________________________________

What accommodations and/or academic adjustments are you requesting the College to provide:

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________
Educational Background:

Name of High School: _________________________________________________

Did you graduate from High School? Yes____ No____ If yes, what year? _________________________

Did you attend Vocational School? Yes____ No____ If yes, what year? ___________________________

Program of study: ____________________________________________

Have you ever attended College? Yes____ No____ If yes, name of College:__________________________

Dates of attendance:____________________________ Number of credits:____________________________

Disability Documentation:

Did you receive Special Education Services in High School? Yes____ No____

If yes, what was the classification? _____________________________________________________________

What kinds of accommodations did you receive in High School? _____________________________________

__________________________________________________________________________________________

Are you working with any outside professionals? Yes____ No____

Name of Professional:_______________________________ Title:___________________________________

Address:________________________________________ Phone:____________________________________

Are you working with outside agencies? Yes____ No____

If yes, name of agency:______________________ Name of contact person:____________________________

Phone number:______________________

By signing this application, I am applying for Disability Services from Middlesex County College and give
permission for the staff of the Disability Services Offices to act on my behalf regarding securing accommodations.


_______________________________________                      _______________________
Signature                                                    Date

Please mail this form to:

Disability Services Office
Middlesex County College
2600 Woodbridge Ave., ED 100
Edison NJ 08818-3050