VOLUNTARY DISCLOSURE FORM
If you are a student with a physical and/or learning disability that will have special needs while attending
Middle Georgia College, please complete and return this form.
This information is not official documentation. This form indicates that you, as a student, are requesting
assistance. This letter is never to be considered as proof of documentation.
A student must give official documentation to the Office of Disability Services before any accommodations on
campus can be considered. The responsibility rests solely with the student.
Please do not send your documentation through the mail or by fax. To insure a complete packet, the student
must make an appointment to meet with the Director of Disability Services. At this meeting, the student can give
their documentation to the director. To make an appointment, please call (478) 934-3023.
Although this self-identification sheet is voluntary, completion of this form is necessary in order to
start the accommodation process.
What is the nature of your disability? (Check all that apply)
Deaf Hearing impaired Cardio-vascular disease
Blind Visually impaired Mobility impaired
Learning Disabled Yes No
Please fill in the following information:
MGC ID #
City: State: Zip
Classification: (Check one)
New freshman Returning student
New transfer Continuing student
By typing my name, I certify that this information is accurate:
Please print out and return this information to:
Middle Georgia College * Office of Disability Services* 1100 Second Street SE *Cochran, GA 31014
E-mail to firstname.lastname@example.org