Accessibility Services Client Profile
Student Name:
Student ID #:
Phone (primary):
Phone (other):
SIN #:
Date of Birth:
Permanent Mailing Address (address used on MyPath):
Mount Email:
Documentation: ☐ Yes ☐ No
Diagnosis:
Name & Phone # of Emergency Contact:
Student Status: ☐ NS Student
☐ Out of Province
☐ International
I have applied for a Student Loan: ☐ Yes ☐ No
# of Courses this Term:
Year of Study:
Program:
Accommodations:
☐ Note-taker
☐ Reader for quizzes/midterms/finals
☐ Tape record lectures
☐ Scribe for quizzes/midterms/finals
☐ Enlarged font (size_______)
☐ Laptop for quizzes/midterms/finals
☐ Extra time for quizzes/midterms/finals
☐ Other:
☐ Extended time for term work (to be negotiated between instructor and student)
How will the above requested accommodations reduce barriers caused by your disability?
Accessibility Services Consent Form
Student Name:
Student Number:
As a student registered with Accessibility Services;
1.
2.
3.
4.
I have reviewed the information on www.msvu.ca/accessibilityservices
I will abide by the stated procedures & deadlines outlined on
www.msvu.ca/accessibilityservices
I will contact each instructor, within the first two weeks of each term to discuss my
accommodations
I will immediately bring forward to Accessibility Services any questions or concerns
Furthermore, I understand that client confidentiality is maintained according to the Psychologists’
Act of Nova Scotia, otherwise, my written consent is required to consult outside of Accessibility
Services, regarding my disability and/or accommodations. However, I do consent to the release of
my information to the Department of Advanced Labour and Education for statistics and/or funding
purposes.
When necessary and to ensure the best possible service, the information pertaining to my
disability and accommodations, may be shared within Accessibility Services.
When recommending academic or other supports on my behalf, information specific to my
accommodations only (the nature of my disability will not be discussed) may be shared with
appropriate University staff at the discretion of Accessibility Services.
In order to provide me with my accommodations, the faculty members of each course I am
requesting accommodations for will be emailed the Proposed Accommodations - Letter to Faculty.
When necessary, consultations may be made with these faculty members specific to my
accommodations only; the nature of my disability will not be discussed.
This release is in effect until I complete my studies at the Mount, however, I understand that I can
revoke or amend this release of information in writing at any time.
I fully understand and agree to the conditions as described in the above statements.
☐ Yes ☐ No
Or if hard-copy, please sign:
Date:
Course & Faculty Information
Student Name:
Student Number:
Phone:
MSVU Email:
Program:
Term:
Date:
Course Subject
(i.e. PSYC)
Course Number
(i.e. 1100)
Course Section
(i.e. 02)
Professor’s Name
Returning Students Only
My accommodations remain the same as last term:
(Yes)
(No)
If you require a change in your accommodations from last term, please contact the
Accessibility Services Coordinator at kim.musgrave@msvu.ca.
Additional or updated documentation may be required to support such changes.