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Voluntary Disclosure

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VOLUNTARY DISCLOSURE FORM


Dear Student:

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:

Name:

MGC ID #

Permanent Address:

City:                                       State:                Zip

Telephone:

Classification: (Check one)

        New freshman                        Returning student

        New transfer                        Continuing student


By typing my name, I certify that this information is accurate:

Date:

Please print out and return this information to:
              Middle Georgia College * Office of Disability Services* 1100 Second Street SE *Cochran, GA 31014

OR

E-mail to achastain@mgc.edu