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Intake Form - Mohave Community College

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Intake Form - Mohave Community College Powered By Docstoc
					                                                                                            1/20/06




                           Disability Services Intake Form
Student Name:                                        Student ID #

Mailing Address:

City:                                State:                                 Zip:

Home Phone:                                   Work Phone:

DOB                            SS#                           Cell Phone #

Email Address: ________________________________________________________________

Emergency Contact:                                                   Phone#:

Disability:
        LD/ADD/ADHD                  Visual/Blind                    Chronic Medical
        Hearing Impairment/Deaf      TBI                             Temporary Injury
        Physical                     Psychological                   Other

Additional Support Agencies Involved:
         Vocational Rehabilitation            Mohave Mental Health
         Veterans Administration              Other
         Workman’s Comp


Would you like assistance in completing paperwork to become a registered voter?
         Yes              No

I understand that I need to provide documentation to develop an accommodation plan to receive
services. As a participant in the Disability Services Program, I give my permission to share
information with other College departments and faculty or outside departments (i.e. VR, Doctor
or Professional Offices, etc.) that will support or enhance the services I am requesting through
this program.


Student Signature                                    Date



Employee Signature                                   Date




Documentation Received                   Date:

				
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